Tenn. Comp. R. & Regs. 1200-13-05-.01 - DEFINITIONS
(1) Bureau of TennCare (Bureau). The
administrative unit of TennCare which is responsible for the administration of
TennCare as defined elsewhere in these rules.
(2) Existing Contracts. The contracts that
were in place between a Tennessee hospital and a TennCare MCO as of July 1,
2013.
(3) Hospital. A general or
specialty acute care facility licensed as a hospital by the Tennessee
Department of Health pursuant to T.C.A. §
68-11-206, excluding hospitals
that are categorized as Rehabilitation, Research, Long Term Acute or
Psychiatric on the 2013 Joint Annual Report of Hospitals.
(4) Inpatient Services. Routine,
nonspecialized services that are provided at many or most hospitals in the
state to patients admitted to the hospital as inpatients.
(5) MCO (Managed Care Organization). An
appropriately licensed Health Maintenance Organization (HMO) contracted with
the Bureau of TennCare to manage the delivery, provide for access, contain the
cost, and ensure the quality of specified covered medical and behavioral
benefits to TennCare enrollee-members through a network of qualified
providers.
(6) Medicare. A
hospital's fee-for-service reimbursement under Title XVIII including that
hospital's adjustment for DSH, wage index, etc., and excluding only Indirect
Medical Education (IME), pass through payments, and any Medicare payment
adjustments for Sequestration, Value Based Purchasing, Readmissions and
Hospital Acquired Conditions.
(7)
Medicare Severity Diagnosis Related Groups (MS-DRG). The Medicare statistical
system of classifying any inpatient stay into groups for the purpose of
payment.
(8) New Contract. Any
initial contract between an MCO and a hospital that did not exist on July 1,
2013. Contracts in place on July 1, 2013, that have been materially altered
since July 1, 2013, are not new contracts.
(9) Outpatient Services. Services that are
provided by a hospital to patients in the outpatient department of the hospital
and patients receiving outpatient observation services.
(10) Rate Corridors. Upper and lower limits
established by the state's actuary and approved by the Bureau, in consultation
with the Tennessee Hospital Association (THA), for payments by MCOs to
hospitals for services provided to TennCare enrollees. The Rate Corridors are
based on a hospital's Medicare reimbursement that existed in FFY 2011 and used
to determine the parameters of TennCare rates for contracts between Tennessee
hospitals and TennCare MCOs after July 1, 2013. The determination of whether a
hospital's TennCare rates are within the prescribed Rate Corridors shall be
made on the basis of reimbursement from all TennCare MCOs with which the
hospital has a contract. The Rate Corridors, which were calculated by the
State's actuary as the budget neutral corridors, are as follows:
(a) For inpatient services, the minimum level
is 53.8% and the maximum level is 80% of the hospital's Medicare for
2011.
(b) For outpatient services,
the minimum level is 93.2% and the maximum level is 104% of the hospital's
Medicare for 2011.
(c) For cardiac
surgery, the minimum level is 32% and the maximum level is 83% of the
hospital's Medicare for 2011.
(d)
For specialized neonatal services the minimum level is 4% and the maximum level
is 174% of the hospital's Medicare for 2011.
(e) For other specialized services the
minimum level is 49% and the maximum level is 164% of the hospital's Medicare
for 2011.
(11)
Specialized Services. Services that are typically provided in a small subset of
hospitals, such as transplants, neonatal intensive care and level 1
trauma.
(12) TennCare. The TennCare
waiver demonstration program(s) and/or Tennessee's traditional Medicaid
program.
(13) TennCare Actuary. The
actuarial firm selected by the Bureau to assist the Bureau in establishing the
capitation rates for TennCare MCOs each year.
(14) Total TennCare Rates. Payment rates for
each hospital in the aggregate from all MCOs with which the hospital has
network contracts.
(15) Year 1
Corridors. The initial upper and lower limits established by the Bureau in
consultation with THA based on a hospital's Medicare reimbursement that existed
in FFY 2011 and that were used to implement rate variation limitations in
contracts between Tennessee hospitals and TennCare MCOs from July 1, 2012 until
July 1, 2013. The Year 1 Corridors are as follows:
(a) For inpatient services, the minimum level
was 40% and the maximum level was 90% of the hospital's Medicare for
2011.
(b) For outpatient services,
the minimum level was 90% and the maximum level was 125% of the hospital's
Medicare for 2011.
(c) For cardiac
surgery, the minimum level was 30% and the maximum level was 80% of the
hospital's Medicare for 2011.
(d)
For specialized neonatal services the minimum level was 4% and the maximum
level was 180% of the hospital's Medicare for 2011.
(e) For other specialized services the
minimum level was 30% and the maximum level was 160% of the hospital's Medicare
for 2011.
Notes
Authority: T.C.A. §§ 4-5-208, 12-4-301, 71-5-105, 71-5-109, and 71-5-2801.
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