Tenn. Comp. R. & Regs. 1200-13-02-.03 - CONDITIONS FOR REIMBURSEMENT OF NURSING FACILITY CARE

(1) A NF must enter into a provider agreement with one (1) or more TennCare MCOs, for reimbursement of NF services.

(2) A NF must be certified by the Tennessee Department of Health, showing that it has met the standards set out in 42 C.F.R. Part 442.

(3) A NF participating in TennCare shall be terminated as a TennCare provider if certification or licensure is canceled by CMS or the State. A NF whose certification was terminated may be recertified to provide Medicaid services and may be contracted to provide Medicaid services at the discretion of the MCOs.

(4) If a resident has resources to apply toward payment, including Patient Liability as determined by TennCare, or TPL, which may include LTC insurance benefits, the payment for NF services shall be the NF's per diem rate for the applicable level of NF reimbursement authorized minus the resident's available resources.

(5) Regardless of the Medicaid reimbursement rate established, a NF may not charge TennCare Enrollees an amount greater than the amount per day charged to Non-Medicaid payer patients for equivalent accommodations and services.

(6) The specific items and services covered by the NF program shall be those defined and approved by TennCare. A NF shall not charge a TennCare enrollee for a covered service. Non-covered services may be charged directly to the resident, upon prior notification by the NF to the resident that the service is not covered. Rule 1200-13-13-.08(5).

Notes

Tenn. Comp. R. & Regs. 1200-13-02-.03

Original rule filed January 18, 1979; effective March 5, 1979. Amendment filed March 8, 1983; effective April 7, 1983. Amendment filed June 23, 1983; effective July 25, 1983. Repeal filed May 5, 2009; effective July 19, 2009. New rules filed May 1, 2018; effective 7/30/2018.

Authority: T.C.A. §§ 4-5-202, 14-23-105, 14-23-109, 71-5-105, 71-5-109, and 71-5-1413.