Tenn. Comp. R. & Regs. 1200-13-01-.29 - TENNESSEE'S SELF-DETERMINATION WAIVER UNDER SECTION 1915(c) OF THE SOCIAL SECURITY ACT (SELF-DETERMINATION MR WAIVER PROGRAM)
(1) Definitions: The following definitions
shall apply for interpretation of this rule:
(a) Adult Dental Services. See definition in
1200-13-01-.02.
(b) Behavioral Respite Services - services
that provide Respite for an Enrollee who is experiencing a behavioral crisis
that necessitates removal from the current residential setting in order to
resolve the behavioral crisis.
(c)
Behavior Services - assessment and amelioration of Enrollee behavior that
presents a health or safety risk to the Enrollee or others or that
significantly interferes with home or community activities; determination of
the settings in which such behaviors occur and the events which precipitate the
behaviors; development, monitoring, and revision of crisis prevention and
behavior intervention strategies; and training of caregivers who are
responsible for direct care of the Enrollee in prevention and intervention
strategies.
(d) Bureau of TennCare
- the bureau in the Tennessee Department of Finance and Administration which is
the State Medicaid Agency and is responsible for administration of the Medicaid
program in Tennessee.
(e) Case
Manager - an individual who assists the Enrollee or potential Enrollee in
gaining access to needed Waiver and other Medicaid State Plan services as well
as other needed services regardless of the funding source; develops the initial
interim Plan of Care and facilitates the development of the Enrollee's Plan of
Care; monitors the Enrollee's needs and the provision of services included in
the Plan of Care; monitors the Enrollee's budget, and authorizes alternative
emergency back-up services for the Enrollee if necessary.
(f) Certification - the process by which a
physician, who is licensed as a doctor of medicine or doctor of osteopathy,
signs and dates a Pre-Admission Evaluation signifying that the named individual
requires services provided through the Tennessee Self-Determination Waiver
Program as an alternative to care in an Intermediate Care Facility for the
Mentally Retarded.
(g) Covered
Services or Covered Waiver Services - The services which are available through
the Tennessee Self-Determination Waiver Program when medically necessary and
when provided in accordance with the Waiver as approved by the Centers for
Medicare and Medicaid Services.
(h)
Day Services - individualized services and supports that enable an Enrollee to
acquire, retain, or improve skills necessary to reside in a community-based
setting; to participate in community activities and utilize community
resources; to acquire and maintain employment; and to participate in retirement
activities.
(i) Denial - as used in
regard to Waiver Services, the term shall mean the termination, suspension, or
reduction in amount, scope, and duration of a Waiver Service or a refusal or
failure to provide such service.
(j) Disenrollment - the voluntary or
involuntary termination of enrollment of an individual receiving services
through the Tennessee Self-Determination Waiver Program.
(k) Emergency Assistance - a supplementary
increase in the amount of approved Covered Waiver Services for the purpose of
preventing the permanent out of home placement of the Enrollee which is
provided in one of the following emergency situations:
1. Permanent or temporary involuntary loss of
the Enrollee's present residence;
2. Loss of the Enrollee's present caregiver
for any reason, including death of a caregiver or changes in the caregiver's
mental or physical status resulting in the caregiver's inability to perform
effectively for the Enrollee; or
3.
Significant changes in the behavioral, medical or physical condition of the
Enrollee that necessitate substantially expanded services.
(l) Enrollee - a Medicaid Eligible who is
enrolled in the Tennessee Self-Determination Waiver Program.
(m) Environmental Accessibility Modifications
- only those interior or exterior physical modifications to the Enrollee's
place of residence which are required to ensure the health, welfare and safety
of the Enrollee or which are necessary to enable the Enrollee to function with
greater independence.
(n) Financial
Administration - a service which facilitates the employment of Waiver Service
providers by the Enrollee and the management of the Enrollee's self-directed
budget and is provided to assure that Enrollee-managed funds specified in the
Plan of Care are managed and distributed as intended. Financial Administration
includes filing claims for Enrollee-managed services and reimbursing individual
Covered Waiver Service providers; deducting all required federal, state and
local taxes, including unemployment fees, prior to issuing reimbursement or
paychecks; making Workers Compensation premium payments for Waiver Service
providers employed by the Enrollee; verifying that goods and services for which
reimbursement is requested have been authorized in the Plan of Care; ensuring
that requests for payment are properly documented and have been approved by the
Enrollee or the Enrollee's guardian or conservator; and assisting the Enrollee
in meeting applicable employer-of-record requirements. It also includes
maintaining a separate account for each Enrollee's self-determination budget;
preparation of required monthly reports detailing disbursements of
self-determination budget funds, the status of the expenditure of
self-determination budget funds in comparison to the budget, and expenditures
for standard method services made by the state on the Enrollee's behalf; and
notification of the Operational Administrative Agency when expenditure patterns
potentially will result in the premature exhaustion of the Enrollee's
self-determination budget. It includes, in addition, verification that
self-managed Waiver Service providers meet the State Medicaid Agency provider
qualification requirements.
(o)
Financial Administration Entity - an entity which meets the State Medicaid
Agency requirements to provide Financial Administration services and which has
been approved by the OAA to provide Financial Administration
services.
(p) Home (of an Enrollee)
- the residence or dwelling in which the Enrollee resides, excluding hospitals,
nursing facilities, Intermediate Care Facilities for the Mentally Retarded,
Assisted Living Facilities and Homes for the Aged
(q) ICF/MR Pre-Admission Evaluation (ICF/MR
PAE) - the assessment form used by the State Medicaid Agency to document the
current medical and habilitative needs of an individual with mental retardation
and to document that the individual meets the Medicaid level of care
eligibility criteria for care in an ICF/MR.
(r) Individual Support Plan - the
individualized written Plan of Care.
(s) Individual Transportation Services -
non-emergency transport of an Enrollee to and from approved activities
specified in the Pan of Care.
(t)
Intermediate Care Facility for the Mentally Retarded (ICF/MR) - a licensed
facility approved for Medicaid vendor reimbursement that provides specialized
services for individuals with mental retardation or related conditions and that
complies with current federal standards and certification requirements for an
ICF/MR.
(u) Medicaid Eligible - an
individual who has been determined by the Tennessee Department of Human
Services to be financially eligible to have the State Medicaid Agency make
reimbursement for covered services.
(v) Medicaid State Plan - the plan approved
by the Centers for Medicare and Medicaid Services which specifies the covered
benefits for the Medicaid program in Tennessee.
(w) Nursing Services - skilled nursing
services that fall within the scope of Tennessee's Nurse Practice Act and that
are directly provided to the Enrollee in accordance with a plan of care.
Nursing Services shall be ordered by the Enrollee's physician, physician
assistant, or nurse practitioner, who shall document the medical necessity of
the services and specify the nature and frequency of the nursing
services.
(x) Nutrition Services -
assessment of nutritional needs, nutritional counseling, and education of the
Enrollee and of caregivers responsible for food purchase, food preparation, or
assisting the Enrollee to eat. Nutrition Services are intended to promote
healthy eating practices and to enable the Enrollee and direct support
professionals to follow special diets ordered by a physician, physician
assistant, or nurse practitioner.
(y) Occupational Therapy Services -
diagnostic, therapeutic, and corrective services which are within the scope of
state licensure. Occupational Therapy Services provided to improve or maintain
current functional abilities as well as prevent or minimize deterioration of
chronic conditions leading to a further loss of function are also included
within this definition.
(z)
Operational Administrative Agency - the approved agency with which the State
Medicaid Agency contracts for the administration of the day-to-day operations
of the Tennessee Self-Determination Waiver Program.
(aa) Orientation and Mobility Services for
Impaired Vision assessment of the ability of an Enrollee who is legally blind
to move independently, safely, and purposefully in the home and community
environment; orientation and mobility counseling; and training and education of
the Enrollee and of caregivers responsible for assisting in the mobility of the
Enrollee.
(bb) Personal Assistance
- the provision of direct assistance with activities of daily living (e.g.,
bathing, dressing, personal hygiene, eating, meal preparation excluding cost of
food), household chores essential to the health and safety of the enrollee,
budget management, attending appointments, and interpersonal and social skills
building to enable the Enrollee to live in a home in the community. It also may
include medication administration as permitted under Tennessee's Nurse Practice
Act.
(cc) Personal Emergency
Response System - a stationary or portable electronic device used in the
Enrollee's place of residence which enables the Enrollee to secure help in an
emergency. The system shall be connected to a response center staffed by
trained professionals who respond upon activation of the electronic
device.
(dd) Physical Therapy
Services - diagnostic, therapeutic, and corrective services which are within
the scope of state licensure. Physical Therapy Services provided to improve or
maintain current functional abilities as well as prevent or minimize
deterioration of chronic conditions leading to a further loss of function are
also included within this definition.
(ee) Plan of Care - an individualized written
Plan of Care which describes the medical and other services (regardless of
funding source) to be furnished to the Enrollee, the Waiver Service frequency,
and the type of provider who will furnish each Waiver Service and which serves
as the fundamental tool by which the State ensures the health and welfare of
Enrollees.
(ff) Qualified Mental
Retardation Professional (QMRP) - an individual who meets current federal
standards, as published in the Code of Federal Regulations, for a qualified
mental retardation professional.
(gg) Re-evaluation - the annual process
approved by the State Medicaid Agency by which a licensed physician or
registered nurse or a Qualified Mental Retardation Professional assesses the
Enrollee's need for continued Waiver Services and certifies in writing that the
Enrollee continues to require Waiver Services.
(hh) Respite - services provided to an
Enrollee when unpaid caregivers are absent or incapacitated due to death,
hospitalization, illness or injury, or when unpaid caregivers need relief from
routine caregiving responsibilities.
(ii) Safety Plan - an individualized plan by
which the Operational Administrative Agency ensures the health, safety and
welfare of Enrollees who do not have 24-hour direct care services.
(jj) Self-Directed or Self-Determined or
Self-Managed - the direct management of one or more Covered Services specified
in subparagraph (2)(b) with the assistance of a Financial Administration Entity
which pays the Enrollee's service providers, handles taxes and other payroll or
benefits related to the employment of the service providers, and provides other
financial administration services as specified in subparagraph
(1)(o).
(kk) Self-Direction or
Self-Determination or Self-Management - the process whereby an Enrollee or the
Enrollee's guardian or conservator directly manages one or more Covered
Services specified in subparagraph (2)(b) with the assistance of a Financial
Administration Entity which pays the Enrollee's service providers, handles
taxes and other payroll or benefits related to the employment of the service
providers, and provides other financial administration services as specified in
subparagraph (1)(o).
(ll)
Specialized Medical Equipment and Supplies and Assistive Technology - assistive
devices, adaptive aids, controls or appliances which enable an Enrollee to
increase the ability to perform activities of daily living, or to perceive,
control or communicate with the environment, and supplies for the proper
functioning of such items. Specialized Medical Equipment, Supplies and
Assistive Technology shall be recommended by a qualified health care
professional (e.g., occupational therapist, physical therapist, speech language
pathologist, physician or nurse practitioner) based on an assessment of the
Enrollee's needs and capabilities and shall be furnished as specified in the
Plan of Care. Specialized Medical Equipment and Supplies and Assistive
Technology may also include a face-to-face consultative assessment by a
physical therapist, occupational therapist or speech therapist to assure that
Specialized Medical Equipment and Assistive Technology which requires custom
fitting meets the needs of the Enrollee and may include training of the
Enrollee by a physical therapist, occupational therapist or speech therapist to
effectively utilize such customized equipment.
(mm) Speech, Language and Hearing Services -
diagnostic, therapeutic and corrective services which are within the scope of
state licensure which enable an Enrollee to improve or maintain current
functional abilities and to prevent or minimize deterioration of chronic
conditions leading to a further loss of function.
(nn) State Medicaid Agency - the Bureau in
the Tennessee Department of Finance and Administration which is responsible for
administration of the Title XIX Medicaid program in Tennessee.
(oo) Subcontractor - an individual, organized
partnership, professional corporation, or other legal association or entity
which enters into a written contract with the Operational Administrative Agency
to provide Waiver Services to an Enrollee.
(pp) Supports Broker - the person or entity
that provides Supports Brokerage services to an Enrollee.
(qq) Supports Brokerage - an activity
designed to enable an Enrollee to manage self-directed services and provide
assistance to the Enrollee to locate, access and coordinate needed services. It
includes provision of training to the Enrollee in Enrollee-managed services;
assistance in the recruitment of individual providers of Enrollee-managed
services and negotiation of payment rates; assistance in the scheduling,
training and supervision of individual providers; assistance in managing and
monitoring the Enrollee's budget; and assistance in monitoring and evaluating
the performance of individual providers. It may also include assistance in
locating and securing services and supports and other community resources that
promote community integration, community membership and independence.
(rr) Tennessee Self-Determination Waiver
Program or "Waiver" - the Home and Community Based Services waiver program
approved for Tennessee by the Centers for Medicare and Medicaid Services to
provide services to a specified number of Medicaid-eligible individuals on the
Waiting List who have mental retardation and who meet the criteria for Medicaid
reimbursement of care in an Intermediate Care Facility for the Mentally
Retarded.
(ss) Transfer Form - the
form approved by the State Medicaid Agency and used to document the transfer of
an Enrollee having an approved unexpired ICF/MR PreAdmission Evaluation from
the Waiver to an ICF/MR, from an ICF/MR to the Waiver or from one MR Waiver
program to another MR Waiver program. For purposes of transfer to an MR Waiver
program, whether from an ICF/MR or from another MR Waiver program, such
Transfer Form shall be processed by TennCare only if submitted by the Division
of Intellectual Disabilities Services (DIDS). DIDS shall submit a Transfer Form
only after verifying that the person otherwise meets all applicable admission
criteria for the applicable MR Waiver program, as the Transfer Form
accomplishes only the transfer of the level of care eligibility.
(tt) Vehicle Accessibility Modifications -
interior or exterior physical modifications to a vehicle owned by the Enrollee
or to a vehicle which is owned by the guardian or conservator of the Enrollee
and which is routinely available for transport of the Enrollee. Such
modifications must be intended to ensure the transport of the Enrollee in a
safe manner.
(uu) Waiting List - a
document prepared and updated by the Operational Administrative Agency which
lists persons who are seeking home and community-based mental retardation
services in Tennessee.
(2) Self-Direction of Covered Services.
(a) Self-Directed Services.
1. The Covered Services specified in
subparagraph (2)(b) may be Self-Directed or Self-Managed by the Enrollee or the
Enrollee's guardian or conservator in accordance with State Medicaid Agency
guidelines.
2. The Enrollee or the
Enrollee's guardian or conservator shall have the right to decide whether to
Self-Direct the Covered Services specified in subparagraph (2)(b) or to receive
them through the provider-directed service delivery method. When the Enrollee
or the Enrollee's guardian or conservator does not choose to Self-Direct a
Covered Service, such service shall be furnished through the provider-directed
service delivery method.
3. When
the Enrollee or the Enrollee's guardian or conservator elects to Self-Direct
one or more of the Covered Services specified in Subparagraph (2)(b), a
Financial Administration Entity must provide Financial Administration
services.
(b) The
following Covered Services may be Self-Directed:
1. Day Services which are not
facility-based.
2. Individual
Transportation Services.
3.
Personal Assistance.
4. Respite
Services when provided by an approved respite provider who serves only one (1)
Enrollee.
(c) The
following Covered Services shall not be Self-Directed:
1. Adult Dental Services.
2. Behavioral Respite Services.
3. Behavior Services.
4. Day Services which are
facility-based.
5. Emergency
Assistance.
6. Nursing
Services.
7. Nutrition
Services.
8. Occupational Therapy
Services.
9. Orientation and
Mobility Training.
10. Personal
Emergency Response Systems.
11.
Physical Therapy Services.
12.
Respite Services when provided by an approved respite provider who serves more
than one (1) Enrollee.
13.
Specialized Medical Equipment and Supplies and Assistive Technology.
14. Speech, Language and Hearing
Services.
(d)
Termination of Self-Direction of Covered Services.
1. Self-Direction of Covered Services by the
Enrollee may be voluntarily terminated by the Enrollee or the Enrollee's
guardian or conservator at any time.
2. Self-Direction of Covered Services by the
Enrollee may be involuntarily terminated for any of the following reasons:
(i) The Enrollee or the Enrollee's guardian
or conservator does not carry out the responsibilities required for the
Self-Direction of Covered Services; or
(ii) Continued use of Self-Direction as the
method of service management would result in the inability of the Operational
Administrative Agency to ensure the health and safety of the
Enrollee.
3. Termination
of Self-Direction of Covered Services shall not affect the Enrollee's receipt
of Covered Services. Covered Services shall continue to be provided through the
provider-directed method of service delivery.
(e) Changing the Amount of Self-Directed
Services by the Enrollee.
1. The Enrollee
shall have the flexibility to change the amount of those Self-Directed Covered
Services specified in subparagraph (2)(b) that have been approved in the
Individual Support Plan if:
(i) The change is
consistent with the needs, goals, and objectives identified in the Individual
Support Plan;
(ii) The change does
not affect the total amount of the Enrollee's self-determination budget;
and
(iii) The Enrollee notifies the
Financial Administration Entity, the Supports Broker (if applicable) and the
Case Manager.
2. The
Case Manager and the Financial Administration Entity shall maintain
documentation of such changes by the Enrollee in the amount of the
Self-Directed Covered Services for audit purposes.
(3) Covered Services and
Limitations.
(a) Adult Dental Services.
1. Adult Dental Services shall not include
hospital outpatient or inpatient facility services or related anesthesiology,
radiology, pathology, or other medical services in such setting.
2. Adult Dental Services shall exclude
orthodontic services.
3. Adult
Dental Services shall be limited to adults age twenty-one (21) years or older
who are enrolled in the Waiver.
4.
Adult Dental Services for adults age 21 or older enrolled in the Waiver shall
be limited to a maximum of $5,000 per member per calendar year, and a maximum
of $7,500 per member across three (3) consecutive calendar years. Adult Dental
Services that are received on or after January 1, 2023, shall apply to the
maximum amount allowable under this rule only if the service is not covered as
part of the Dental Services benefit outlined in
1200-13-13-.04 and
1200-13-14-.04. Any Adult Dental
Services received prior to January 1, 2023, shall apply to the maximum amounts
allowable for the qualifying time period during which the service was performed
as outlined by this rule.
(b) Behavioral Respite Services.
1. Behavioral Respite Services may be
provided in a Medicaid-certified ICF/MR, in a licensed respite care facility,
or in a home operated by a licensed residential provider.
2. Reimbursement shall not be made for the
cost of room and board except when provided as part of Behavioral Respite
Services furnished in a facility approved by the State that is not a private
residence.
3. Enrollees who receive
Behavioral Respite Services shall be eligible to receive Individual
Transportation Services only to the extent necessary during the time period
when Behavioral Respite Services is being provided.
(c) Behavior Services.
1. Behavior Services shall not be billed when
provided during the same time period as Physical Therapy; Occupational Therapy;
Nutrition Services; Orientation and Mobility Training; or Speech, Language and
Hearing Services, unless there is documentation in the Enrollee's record of
medical justification for the two services to be provided
concurrently.
2. Behavior Services
shall be provided face to face with the Enrollee except Enrollee-specific
training of staff; behavior assessment and plan development; and presentation
of Enrollee behavior information at human rights committee meetings, behavior
support committee meetings, and Enrollee planning meetings.
3. Reimbursement for presentation of Enrollee
behavior information at meetings shall be limited to a maximum of five (5)
hours per Enrollee per year per provider. Reimbursement for behavior
assessments shall be limited to a maximum of eight (8) hours per assessment
with a maximum of two (2) assessments per year. Reimbursement for behavior plan
development resulting from such a behavior assessment and the training of staff
on the plan during the first thirty (30) days following its approval for use
shall be limited to a maximum of six (6) hours.
(d) Day Services.
1. Day Services may be provided in settings
such as specialized facilities licensed to provide Day Services, community
centers or other community sites, or job sites. Services may also be provided
in the Enrollee's place of residence if there is a health, behavioral, or other
medical reason or if the Enrollee has chosen retirement. This service shall not
be provided in inpatient hospitals, nursing facilities, and Intermediate Care
Facilities for the Mentally Retarded (ICF/MR's).
2. Day Services provided in a provider's day
habilitation facility shall be provided during the provider agency's normal
business hours.
3. Transportation
to and from the Enrollee's place of residence to Day Services and
transportation that is needed during the time that the Enrollee is receiving
Day Services shall be a component of Day Services and shall be included in the
Day Services reimbursement rate (i.e., it shall not be billed as a separate
Waiver service) with the following exceptions:
(i) Transportation to and from medical
services covered through the Medicaid State Plan, which shall not be billed as
a Waiver service; or
(ii)
Transportation necessary for Orientation and Mobility Training.
4. Day Services shall not replace
services available under a program funded by the Rehabilitation Act of 1973 or
the Individuals with Disabilities Education Act.
5. For an Enrollee receiving employment
supports, reimbursement shall not be made for incentive payments, subsidies or
unrelated vocational training expenses such as the following:
(i) Incentive payments made to an employer to
encourage or subsidize the employer's participation in a supported employment
program;
(ii) Payments that are
passed through to users of supported employment programs; or
(iii) Payments for vocational training that
is not directly related to an Enrollee's supported employment
program.
(e)
Environmental Accessibility Modifications.
1.
Environmental Accessibility Modifications which are considered improvements to
the home (e.g., roof or flooring repair, installing carpet, installation of
central air conditioning, construction of an additional room) are excluded from
coverage.
2. Any modification which
is not of direct medical or remedial benefit to the Enrollee is excluded from
coverage.
3. Modification of an
existing room which increases the total square footage of the home is also
excluded unless the modification is necessary to improve the accessibility of
an Enrollee having limited mobility, in which case the modification shall be
limited to the minimal amount of square footage necessary to accomplish the
increased accessibility.
(f) Individual Transportation Services.
Individual Transportation Services shall not be used for:
1. Transportation to and from Day
Services;
2. Transportation to and
from supported or competitive employment;
3. Transportation of school aged children to
and from school; or
4.
Transportation to and from medical services covered by the Medicaid State
Plan.
(g)
Reserved.
(h) Nursing Services.
1. Nursing Services shall be provided face to
face with the Enrollee by a licensed registered nurse or licensed practical
nurse under the supervision of a registered nurse.
2. Nursing assessment and/or nursing
oversight shall not be a separate billable service under this
definition.
3. This service shall
be provided in home and community settings, as specified in the Plan of Care,
excluding inpatient hospitals, nursing facilities, and Intermediate Care
Facilities for the Mentally Retarded (ICF/MR's).
4. Nursing Services shall not be billed when
provided during the same time period as other therapies unless there is
documentation in the Enrollee's record of medical justification for the two
services to be provided concurrently.
5. Nursing Services are not intended to
replace services available through the Medicaid State Plan or services
available under the Rehabilitation Act of 1973 or Individuals with Disabilities
Education Act.
(i)
Nutrition Services.
1. Nutrition Services
must be provided face to face with the Enrollee except for Enrollee-specific
training of caregivers responsible for food purchase, food preparation, or
assisting the Enrollee to eat and except for that portion of the assessment
involving development of the POC.
2. Nutrition Services shall not be billed
when provided during the same time period as Physical Therapy; Occupational
Therapy; Speech, Language and Hearing Services; Orientation and Mobility
Training; or Behavior Services, unless there is documentation in the Enrollee's
record of medical justification for the two services to be provided
concurrently.
3. Reimbursement for
a Nutrition Services assessment visit, which includes the Nutritional Services
plan development resulting from such an assessment, shall be limited to one (1)
assessment visit per month with a maximum of three (3) assessment visits per
year per Enrollee per provider Nutrition Services other than such assessments
(e.g., Enrollee-specific training of caregivers; monitoring dietary compliance
and food preparation) shall be limited to a maximum of one (1) visit per day.
Nutrition Services assessments shall not be billed on the same day with other
Nutrition Services.
(j)
Occupational Therapy Services.
1. Services
must be provided by a licensed occupational therapist or by a licensed
occupational therapist assistant working under the supervision of a licensed
occupational therapist.
2.
Occupational Therapy must be provided face to face with the Enrollee except for
that portion of the assessment involving development of the POC.
3. Occupational Therapy therapeutic and
corrective services shall not be ordered concurrently with Occupational Therapy
assessments (i.e., assess and treat orders are not accepted).
4. Occupational Therapy assessments shall not
be billed on the same day with other Occupational Therapy services.
5. Occupational Therapy shall not be billed
when provided during the same time period as Physical Therapy; Speech, Language
and Hearing Services; Nutrition Services; Orientation and Mobility Training; or
Behavior Services, unless there is documentation in the Enrollee's record of
medical justification for the two services to be provided concurrently.
Occupational Therapy shall not be billed with Day Services if the Day Services
are reimbursed on a per hour basis.
6. Occupational Therapy services are not
intended to replace services available through the Medicaid State Plan or
services available under the Rehabilitation Act of 1973 or Individuals with
Disabilities Education Act.
7.
Reimbursement for an Occupational Therapy assessment with development of an
Occupational Therapy plan based on such an assessment shall be limited to a
maximum of one (1) assessment with plan development per month with a maximum of
three (3) assessments per year per Enrollee per provider. Occupational Therapy
services other than such assessments (e.g., Enrollee-specific training of
caregivers; provision of therapeutic services; monitoring progress) shall be
limited to a maximum of one and one-half (1.5) hours per Enrollee per
day.
(k) Orientation and
Mobility Services for Impaired Vision.
1.
Orientation and Mobility Services for Impaired Vision shall not be billed when
provided during the same time period as Physical Therapy; Occupational Therapy;
Nutrition Services; Behavior Services; or Speech, Language and Hearing
Services, unless there is documentation in the Enrollee's record of medical
justification for the two (2) services to be provided concurrently.
2. Orientation and Mobility Services for
Impaired Vision shall not replace services available under a program funded by
the Rehabilitation Act of 1973 or Individuals with Disabilities Education
Act.
3. Reimbursement for an
Orientation and Mobility Services for Impaired Vision assessment with
development of the Orientation and Mobility Services for Impaired Vision plan
based on such an assessment shall be limited to a maximum of one (1) assessment
with plan development per month with a maximum of three (3) assessments per
year per Enrollee per provider. Orientation and Mobility Services for Impaired
Vision assessments shall not be billed on the same day with other Orientation
and Mobility services. Orientation and Mobility Services for Impaired Vision
other than such assessments (e.g., Enrollee training; Enrollee-specific
training of caregivers), which shall be reimbursed on a per diem basis, shall
be limited to a maximum of fifty-two (52) hours of services per Enrollee per
year.
(l) Personal
Assistance.
1. Personal Assistance may be
provided in the home or community; however, it shall not be provided in school
settings and shall not be provided to replace personal assistance services
required to be covered by schools or services available through the Medicaid
State Plan.
2. Personal Assistance
shall not be provided during the same time period when the Enrollee is
receiving Day Services.
3. This
service shall not be provided in inpatient hospitals, nursing facilities, and
Intermediate Care Facilities for the Mentally Retarded (ICF/MR's).
4. Family members who provide Personal
Assistance must meet the same standards as providers who are unrelated to the
Enrollee. The Personal Assistance provider shall not be the spouse and shall
not be the Enrollee's parent if the Enrollee is a minor. Reimbursement shall
not be made to any other individual who is a conservator unless so permitted in
the Order for Conservatorship.
(m) Personal Emergency Response System. The
system shall be limited to those who are alone for parts of the day and who
have demonstrated mental and physical capability to utilize such a system
effectively.
(n) Physical Therapy
Services.
1. Services must be provided by a
licensed physical therapist or by a licensed physical therapist assistant
working under the supervision of a licensed physical therapist.
2. Physical Therapy must be provided face to
face with the Enrollee except for that portion of the assessment involving
development of the POC.
3. Physical
Therapy therapeutic and corrective services shall not be ordered concurrently
with Physical Therapy assessments (i.e., assess and treat orders are not
accepted).
4. Physical Therapy
assessments shall not be billed on the same day with other Physical Therapy
services.
5. Physical Therapy shall
not be billed when provided during the same time period as Occupational
Therapy; Speech, Language and Hearing Services; Nutrition Services; Orientation
and Mobility Training; or Behavior Services, unless there is documentation in
the Enrollee's record of medical justification for the two services to be
provided concurrently. Physical Therapy shall not be billed with Day Services
if the Day Services are reimbursed on a per hour basis.
6. Physical Therapy services are not intended
to replace services available through the Medicaid State Plan or services
available under the Rehabilitation Act of 1973 or Individuals with Disabilities
Education Act.
7. Reimbursement for
a Physical Therapy assessment with development of a Physical Therapy plan based
on such an assessment shall be limited to a maximum of one (1) assessment with
plan development per month with a maximum of three (3) assessments per year per
Enrollee per provider. Physical Therapy services other than such assessments
(e.g., Enrollee-specific training of caregivers; provision of therapeutic
services; monitoring progress) shall be limited to a maximum of one and
one-half (1.5) hours per Enrollee per day.
(o) Respite.
1. Respite may be provided in the Enrollee's
place of residence, in a Family Model Residential Support home, in a
Medicaid-certified ICF/MR, in a home operated by a licensed residential
provider, or in the home of an approved respite provider.
2. The cost of room and board shall be
excluded from Respite reimbursement if Respite is provided in a private
residence.
3. Enrollees who receive
Respite shall be eligible to receive Individual Transportation Services only to
the extent necessary during the time period when Respite is being
provided.
(p)
Specialized Medical Equipment and Supplies and Assistive Technology.
1. Items not of direct medical or remedial
benefit to the Enrollee shall be excluded. Items that would be covered by the
Medicaid State Plan shall be excluded from coverage. Swimming pools, hot tubs,
health club memberships, and recreational equipment are excluded. Prescription
and over-the-counter medications, food and food supplements, and diapers and
other incontinence supplies are excluded.
2. When medically necessary and not covered
by warranty, repair of equipment may be covered when it is substantially less
expensive to repair the equipment rather than to replace it.
3. The purchase price for waiver-reimbursed
Specialized Medical Equipment, Supplies and Assistive Technology shall be
considered to include the cost of the item as well as basic training on
operation and maintenance of the item.
4. Specialized Medical Equipment and Supplies
and Assistive Technology, as defined by
1200-13-01-.29, and Enabling
Technology, as defined by
1200-13-01-.02, shall be limited
to a combined maximum benefit of $10,000 per person supported per two (2)
consecutive calendar years.
(q) Speech, Language and Hearing Services.
1. Services must be provided by a licensed
speech language pathologist or by a licensed audiologist.
2. Speech, Language and Hearing Services must
be provided face to face with the Enrollee except for that portion of the
assessment involving development of the POC.
3. Speech, Language and Hearing therapeutic
and corrective services shall not be ordered concurrently with Speech, Language
and Hearing assessments (i.e., assess and treat orders are not
accepted).
4. Speech, Language and
Hearing Services assessments shall not be billed on the same day with other
Speech, Language and Hearing Services.
5. Speech, Language and Hearing Services
shall not be billed when provided during the same time period as Physical
Therapy; Occupational Therapy; Nutrition Services; Orientation and Mobility
Training; or Behavior Services, unless there is documentation in the Enrollee's
record of medical justification for the two services to be provided
concurrently. Speech, Language and Hearing Services shall not be billed with
Day Services if the Day Services are reimbursed on a per hour basis.
6. Reimbursement for a Speech, Language, and
Hearing Services assessment with development of a Speech, Language, and Hearing
Services plan based on such an assessment shall be limited to a maximum of one
(1) assessment with plan development per month with a maximum of three (3)
assessments per year per Enrollee per provider. Speech, Language, and Hearing
Services other than such assessments (e.g., Enrollee-specific training of
caregivers; provision of therapeutic services; monitoring progress) shall be
limited to a maximum of one and one-half (1.5) hours per Enrollee per
day.
(r) Vehicle
Accessibility Modifications. Replacement of tires or brakes, oil changes, and
other vehicle maintenance procedures shall be excluded from coverage.
(s) Out-of-State Services. A provider of
Personal Assistance may provide Personal Assistance outside the State of
Tennessee and be reimbursed only when provided in accordance with the
following:
1. Personal Assistance provided
out of state shall be for the purpose of visiting relatives or for vacations
and shall be included in the Enrollee's Plan of Care. Trips to casinos or other
gambling establishments shall be excluded from coverage.
2. Personal Assistance provided out of state
shall be limited to a maximum of fourteen (14) days per Enrollee per
year.
3. The Personal Assistance
provider must be able to assure the health and safety of the Enrollee during
the period when Personal Assistance will be provided out of state and must be
willing to assume the additional risk and liability of provision of Personal
Assistance out of state.
4. During
the period when Personal Assistance is being provided out of state, staffing by
qualified Personal Assistance staff shall be maintained in accordance with the
Individual Support Plan to meet the needs of the Enrollee.
5. The Personal Assistance provider or
provider agency which provides Personal Assistance out of state shall not
receive any additional reimbursement for provision of services out-of-state.
The costs of travel, lodging, food, and other expenses incurred by Personal
Assistance staff during the provision of out-of-state Personal Assistance shall
not be reimbursed through the Waiver. The costs of travel, lodging, food, and
other expenses incurred by the Enrollee while receiving out-of-state Personal
Assistance shall be the responsibility of the Enrollee and shall not be
reimbursed through the waiver.
(t) Emergency Assistance.
1. Emergency Assistance shall be provided
only in one of the following emergency situations:
(i) Permanent or temporary involuntary loss
of the Enrollee's present residence;
(ii) Loss of the Enrollee's present caregiver
for any reason, including death of a caregiver or changes in the caregiver's
mental or physical status resulting in the caregiver's inability to perform
effectively for the Enrollee; or
(iii) Significant changes in the behavioral,
medical or physical condition of the Enrollee that necessitate substantially
expanded services.
2.
Emergency Assistance shall be available only to Enrollees whose needs cannot be
accommodated within the $30,000 budget limitation on Covered Waiver
Services.
3. The amount of
Emergency Assistance shall be limited to $6,000 per Enrollee per year. Prior
authorization by the Enrollee's Case Manager shall be required and shall be
renewed every thirty (30) calendar days.
4. Emergency Assistance shall only be used to
provide a supplementary increase in the amount of other Covered Waiver
Services.
(u) The cost
of all Covered Services, including any Emergency Assistance, shall not exceed
$42,000 per year per Enrollee.
(v)
All Covered Services to be provided prior to the development of the initial
Individual Support Plan must be included in the physician's plan of care
section of the PreAdmission Evaluation application.
(4) Eligibility.
(a) To be eligible for enrollment in the
Waiver, an individual must meet all of the following criteria:
1. The individual must be a resident of the
State of Tennessee.
2. The
individual shall have an established non-institutional place of residence and
shall not require staff-supported residential services provided through a Home
and Community Based Services Waiver (e.g., Residential Habilitation and
Supported Living as defined in TennCare rule
1200-13-01-.25).
3. The individual must, but for the provision
of Waiver Services, require the level of care provided in an ICF/MR, and must
meet the ICF/MR eligibility criteria specified in TennCare Rule
1200-13-01-.15, except that
requirements pertaining to a psychological evaluation shall be in accordance
with Rule
1200-13-01-.29(4)(a)
6.
4. The individual's
habilitative, medical, and specialized services needs must be such that they
can be effectively and safely met through the Waiver, as determined by the
Operational Administrative Agency based on a pre-enrollment
assessment.
5. The individual must
have an unexpired ICF/MR Pre-Admission Evaluation which has been approved by
the State Medicaid Agency or by its designee and which lists the Enrollee's
specific Waiver Services with the amount, scope, and duration of the
services.
6. The individual must
have a psychological evaluation included as part of the approved Pre-Admission
Evaluation which meets the following:
(i) The
psychological evaluation shall document that the individual:
(I) Has mental retardation manifested before
eighteen (18) years of age and has an IQ test score of seventy (70) or below;
or
(II) Is a child five (5) years
of age or younger who has a developmental disability with a high probability of
resulting in mental retardation (i.e., a condition of substantial developmental
delay or specific congenital or acquired condition with a high probability of
resulting in mental retardation); and
(ii) There is no time limit for when the
psychological evaluation is conducted as long as it is completed prior to the
submission of the PAE, and as long as the evaluation meets the requirements
specified in
1200-13-01-.29(4)(a)
6.(i) above, and the person's current medical, social, developmental and
psycho-social history continues to support the evaluation.
(iii) A new psychological evaluation
performed within ninety (90) calendar days preceding the date of admission into
the waiver shall be required if the person's condition has significantly
changed, or the original evaluation is not otherwise consistent with the
person's current medical, social, developmental and psycho-social
history.
7. The
individual shall have one or more designated adults who shall be present in the
individual's home to observe, evaluate, and provide an adequate level of direct
care services to ensure the health and safety of the individual.
(i) An individual who does not have
24-hour-per-day direct care services shall:
(I) Have an individualized Safety Plan that:
I. Is based on a written assessment of the
individual's functional capabilities and habilitative, medical, and specialized
services needs by the Case Manager in consultation with individuals who are
knowledgeable of the individual's capability of functioning without direct care
services twenty-four (24) hours per day;
II. Addresses the individual's capability of
functioning when direct care staff are not present;
III. Addresses the ability of the individual
to self-administer medications when direct care staff are not
present;
IV. Specifies whether a
Personal Emergency Response System will be used by the individual to secure
help in an emergency;
V. Is updated
as needed, but no less frequently than annually, by the Operational
Administrative Agency to ensure the health and safety of the individual;
and
VI. Is an attachment to the
ICF/MR PAE or, if applicable, to the Transfer Form.
(II) Have one or more designated adults who
shall be present in the individual's home to observe, evaluate, and provide an
adequate level of direct care services to ensure the health and safety of the
individual as needed but no less frequently than one day each week.
8. The individual shall
have a place of residence with an environment that is adequate to reasonably
ensure health, safety and welfare.
(b) A Transfer Form approved by the State
Medicaid Agency:
1. May be used to transfer an
Enrollee having an approved unexpired ICF/MR PAE from the Waiver to an
ICF/MR;
2. May be used to transfer
an individual having an approved unexpired ICF/MR PAE from an ICF/MR to the
Waiver;
3. May be used to transfer
an individual from one MR Waiver to a different Home and Community Based
Services MR Waiver Program as specified in
1200-13-01-.29(1)(ss)
above; and
4. Shall include an
initial plan of care that lists the Enrollee's specific Waiver Services with
the amount, scope, and duration of the services.
(5) Intake and Enrollment.
(a) When an individual is determined to be
likely to require the level of care provided by an ICF/MR, the Operational
Administrative Agency shall inform the individual or the individual's legal
representative of any feasible alternatives available under the Waiver and
shall offer the choice of available institutional services or Waiver program
services. Notice to the individual shall contain:
1. A simple explanation of the Waiver and
Covered Services;
2. Notification
of the opportunity to apply for enrollment in the Waiver and an explanation of
the procedures for enrollment; and
3. A statement that participation in the
Waiver is voluntary.
(b)
Enrollment in the Waiver shall be voluntary, but shall be restricted to the
maximum number of individuals specified in the Waiver, as approved by the
Centers for Medicare and Medicaid Services for the State of
Tennessee.
(c) Upon implementation
of the ECF CHOICES program, all new enrollment into the Self-Determination
Waiver shall be closed; provided, however, that a child age 18"21 who has an
Intellectual Disability and is aging out of State custody or is determined by
TennCare to no longer be able to safely continue living with their family may
be enrolled into the Self-Determination Waiver subject to (b) above if all
eligibility and enrollment criteria are met, only until such time that the
State has authority under the terms and conditions of the 1115 Waiver to
provide for enrollment of such child into ECF CHOICES, when
appropriate.
(6)
Certification and Re-evaluation.
(a) The
ICF/MR Pre-Admission Evaluation shall include a signed and dated certification
by the individual's physician that the individual requires Waiver
Services.
(b) The Operational
Administrative Agency shall perform a re-evaluation of the Enrollee's need for
continued stay in the Waiver within twelve (12) calendar months of the date of
enrollment and at least every twelve (12) months thereafter. The re-evaluation
shall be documented in a format approved by the State Medicaid Agency and shall
be performed by a licensed physician or registered nurse or a Qualified Mental
Retardation Professional.
(c) The
Operational Administrative Agency shall maintain in its files for a minimum
period of three (3) years a copy of the re-evaluations of need for continued
stay.
(7) Disenrollment.
(a) Voluntary disenrollment of an Enrollee
from the Waiver may occur at any time upon written notice from the Enrollee or
the Enrollee's guardian or conservator to the Operational Administrative
Agency. Prior to disenrollment the Operational Administrative Agency shall
provide reasonable assistance to the Enrollee in locating appropriate
alternative placement.
(b) An
Enrollee may be involuntarily disenrolled from the Waiver for any of the
following reasons:
1. The Tennessee
Self-Determination Waiver Program is terminated.
2. An Enrollee becomes ineligible for
Medicaid or is found to be erroneously enrolled in the Waiver.
3. An Enrollee moves out of the State of
Tennessee; provided however, that when the Enrollee is the dependent of a
military service member who is a legal resident of the state, but has left the
state temporarily due to the military service member's military assignment out
of state, such dependent may re-enroll in the Waiver upon return to the State,
so long as all conditions of eligibility are met.
4. The condition of the Enrollee improves
such that the Enrollee no longer requires the level of care provided by the
Waiver.
5. The Enrollee's medical
or behavioral needs become such that the health, safety and welfare of the
Enrollee cannot be assured through the provision of Waiver Services.
6. The home or home environment of the
Enrollee becomes unsafe to the extent that it would reasonably be expected that
Waiver Services could not be provided without significant risk of harm or
injury to the Enrollee or to individuals who provide covered services to the
Enrollee.
7. The Enrollee or the
Enrollee's guardian or conservator refuses to abide by the Plan of Care or
related Waiver policies, resulting in the inability of the Operational
Administrative Agency to ensure quality care or the health and safety of the
Enrollee.
8. The health, safety and
welfare of the Enrollee cannot be assured due to the lack of an approved Safety
Plan.
9. The Enrollee was
transferred to a hospital, NF, ICF/MR, Assisted Living Facility, and/or Home
for the Aged and has resided there for a continuous period exceeding one
hundred twenty (120) days, if such period began prior to March 1, 2010, or a
period exceeding ninety (90) days if such period begins on or after March 1,
2010.
10. The cost for all Covered
Waiver services, including Emergency Assistance services, has reached the
Waiver limit of $36,000 per year per Enrollee and the State cannot assure the
health and safety of the Enrollee.
(c) The Operational Administrative Agency
shall notify the State Medicaid Agency in writing prior to involuntary
disenrollment of an Enrollee and shall give advance notice to the Enrollee of
the intended involuntary disenrollment and of the Enrollee's right to appeal
and have a fair hearing.
(d) If an
Enrollee has been involuntarily disenrolled from the Waiver, the Operational
Administrative Agency shall provide reasonable assistance to the Enrollee in
locating appropriate alternative placement.
(8) Plan of Care.
(a) All Waiver Services for the Enrollee
shall be provided in accordance with an approved Plan of Care.
1. Prior to the development of the initial
Individual Support Plan, Covered Services shall be provided in accordance with
the physician's initial plan of care included in the approved ICF/MR
Pre-Admission Evaluation.
2. Each
Enrollee shall have an individualized written Plan of Care (the Individual
Support Plan) that shall be developed for an Enrollee within sixty (60)
calendar days of admission into the Waiver.
3. A Safety Plan for Enrollees who do not
have 24-hour direct care services shall be maintained with the Plan of
Care.
(b) To ensure that
Waiver Services and other services are being appropriately provided to meet the
Enrollee's needs, the Plan of Care shall be reviewed on an ongoing basis and
shall be updated and signed in accordance with the following:
1. The Case Manager shall review the Plan of
Care when needed, but no less frequently than once each calendar month, and
shall document such review by a dated signature.
2. A team consisting of the Case Manager and
other appropriate participants in the development of the Plan of Care shall
review the Plan of Care when needed, but no less frequently than every twelve
(12) calendar months, and shall document such review by dated signatures. Such
annual review shall include, but not be limited to, reviewing outcomes and
determining if progress is being made in accordance with the Plan of Care;
reviewing the appropriateness of supports and services being provided and
determining further needs of the Enrollee.
(9) Physician Services.
(a) The Operational Administrative Agency
shall ensure that each Enrollee receives physician services as needed and that
each Enrollee has a medical examination, documented in the Enrollee's record,
in accordance with the following schedule:
Age |
Minimum frequency of medical examinations |
Up to age 21 |
In accordance with Medicaid EPSDT periodicity standards |
21-64 |
Every one (1) to three (3) years, as determined by the Enrollee's physician |
Over age 65 |
Annually |
(b)
All Covered Services to be provided prior to the development of the initial
Individual Support Plan shall be physician ordered and shall be included in the
physician's plan of care section of the Pre-Admission Evaluation
application.
(c) When required by
state law, Covered Services shall be ordered or reordered, by a licensed
physician, licensed nurse practitioner, physician assistant, a licensed
dentist, or other appropriate health care provider.
(10) Waiver Administration. The Operational
Administrative Agency shall be responsible for the administration of the
day-to-day operations of the Waiver under the oversight of the State Medicaid
Agency and shall ensure that Covered Services are provided in accordance with
state and federal laws, rules, regulations and policies established by the
State Medicaid Agency. The Operational Administrative Agency shall be
responsible for the following activities, whether provided directly or through
subcontract:
(a) Marketing of the Waiver to
potential Enrollees;
(b) Intake and
pre-enrollment assessment of the applicant's habilitative, medical and
specialized services needs; and appropriateness for enrollment in the
Waiver;
(c) Assisting the applicant
with the submission of a properly completed ICF/MR PreAdmission
Evaluation;
(d) Enrollment of
eligible individuals into the Waiver;
(e) Provision of a plain language explanation
of appeal rights to each Enrollee upon enrollment in the Waiver;
(f) Review and approval of Plans of Care
(Individual Support Plans) to ensure that Waiver Services have been authorized
prior to payment;
(g) Ensuring that
annual level of care re-evaluations have been performed to document the need
for continuation of Waiver Services for the Enrollee;
(h) Notification of the State Medicaid Agency
in writing prior to involuntary disenrollment of any Enrollee;
(i) Ensuring that Waiver providers maintain
comprehensive Enrollee records and documentation of services provided to
Enrollees in accordance with state and federal laws, rules, regulations and
State Medicaid Agency policies;
(j)
Obtaining approval from the State Medicaid Agency prior to distributing
policies and procedures to Waiver providers or Waiver information to
Enrollees;
(k) Compliance with
reporting and record-keeping requirements established by the State Medicaid
Agency;
(l) Maintaining in its
files the original ICF/MR Pre-Admission Evaluation and, where applicable, the
original Transfer Form;
(m)
Assurance of a statewide provider network adequate to meet the needs of
Enrollees;
(n) Ensuring that Waiver
Services providers and subcontractors meet the Waiver provider qualifications
approved by the Centers for Medicare and Medicaid Services;
(o) Ensuring that Waiver Services providers
have a signed provider agreement which includes a requirement for compliance
with the Division of Mental Retardation Services Provider Manual in the
delivery of waiver services;
(p)
Assurance of the health and safety of Enrollees through the implementation of a
comprehensive quality monitoring program;
(q) Reporting instances of abuse, neglect,
mistreatment or exploitation to appropriate state agencies;
(r) Assurance that Covered Services are
provided in accordance with the approved Waiver definitions and in accordance
with the State Medicaid Agency guidelines;
(s) Compliance with the appeals process
specified in TennCare rule
1200-13-13-.11 to ensure that
Enrollees are afforded advance notice and the right to appeal an adverse
decision and have a fair hearing;
(t) Ensuring that providers and
subcontractors comply with the quality monitoring guidelines and requirements
established by the State Medicaid Agency, by the Operational Administrative
Agency, and by the Centers for Medicare and Medicaid Services, and with other
state and federal laws, rules, and regulations affecting the provision of
Waiver Services;
(u) Oversight and
monitoring of the Financial Administration entity;
(v) Collection of applicable patient
liability from Enrollees;
(w)
Reimbursement of Waiver providers in accordance with policies established by
the State Medicaid Agency;
(x)
Recoupment of payments made to Waiver providers when there is lack of
documentation to support that services were provided or there is a lack of
medical necessity of services, or when inappropriate payments have been made
due to erroneous or fraudulent billing; and
(y) Expenditure and revenue reporting in
accordance with state and federal requirements.
(11) Reimbursement.
(a) The average per capita fiscal year
expenditure under the Waiver shall not exceed 100% of the average per capita
expenditure that would have been made in the fiscal year if care had been
provided in an ICF/MR. The total Medicaid expenditure for Waiver Services and
other Medicaid services provided to Enrollees shall not exceed 100% of the
amount that would have been incurred in the fiscal year if care was provided in
an ICF/MR. Reimbursement for the cost of all Covered Services, including any
Emergency Assistance, shall not exceed $42,000 per year per Enrollee.
(b) The Operational Administrative Agency
shall be reimbursed for Waiver Services at the rate per unit of service
actually paid by the Operational Administrative Agency to the Waiver service
provider or at the maximum rate per unit of service established by the State
Medicaid Agency, whichever is less.
(c) In accordance with
42 CFR §
435.726, the Operational Administrative
Agency shall make a diligent effort to collect patient liability if it applies
to the Enrollee. The Operational Administrative Agency or its designee shall
complete appropriate forms showing the individual's amount of monthly income
and shall submit them to the Tennessee Department of Human Services. The
Tennessee Department of Human Services shall issue the appropriate forms to the
Operational Administrative Agency and to the State Medicaid Agency's fiscal
agent that processes and pays vendor claims, specifying the amount of patient
liability to be applied toward the cost of care for the Enrollee.
(d) The Operational Administrative Agency
shall submit bills for services to the State Medicaid Agency's fiscal agent
using a claim form approved by the State Medicaid Agency. On claim forms, the
Operational Administrative Agency shall use a provider number assigned by the
State Medicaid Agency.
(e)
Reimbursement shall not be made to the Operational Administrative Agency for
therapeutic leave or hospital leave for Enrollees in the Waiver.
(f) Medicaid benefits other than those
specified in the Waiver's scope of Covered Services shall be reimbursed by the
State Medicaid Agency as otherwise provided for by federal and state rules and
regulations.
(g) The Operational
Administrative Agency shall be responsible for obtaining the physician's
initial certification and subsequent Enrollee re-evaluations. Failure to
perform re-evaluations in a timely manner and in the format approved by the
State Medicaid Agency shall require a corrective action plan and shall result
in partial or full recoupment of all amounts paid by the State Medicaid Agency
during the time period when a re-evaluation had lapsed.
(h) The Operational Administrative Agency
shall be responsible for ensuring that the Financial Administration entity
fulfills its financial, ministerial, and clerical responsibilities associated
with the provision of Financial Administration services to an Enrollee who
Self-Directs one or more Covered Services. Examples of such responsibilities
include the hiring and employment of service providers by the Enrollee or the
Enrollee's guardian or conservator; management of Enrollee accounts;
disbursement of funds to Waiver service providers while withholding appropriate
deductions; reviewing documentation of Covered Services to assure Enrollee
approval prior to payment; ensuring that Waiver service providers possess the
necessary qualifications established by the State Medicaid Agency.
(i) The State Medicaid Agency shall be
responsible for defining and establishing the billing units to be used by the
Operational Administrative Agency in billing for Waiver Services.
(j) An Operational Administrative Agency that
enrolls an individual without an approved ICF/MR Pre-Admission Evaluation or,
where applicable, an approved Transfer Form does so without the assurance of
reimbursement. An Operational Administrative Agency that enrolls an individual
who has not been determined by the Tennessee Department of Human Services to be
financially eligible to have Medicaid make reimbursement for covered services
does so without the assurance of reimbursement.
(12) Appeals. An Enrollee shall have the
right to appeal an adverse action in accordance with TennCare rule
1200-13-13-.11.
Notes
Authority: T.C.A. §§ 4-5-202, 4-5-208, 4-5-209, 71-5-105, 71-5-107, and 71-5-109 and Executive Order No. 23.
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No prior version found.