Tenn. Comp. R. & Regs. 1200-13-21-.05 - [Effective until 2/3/2025] BENEFITS
(1) The following
benefits are covered by the CoverKids program for children under age 19 as
medically necessary, subject to the limitations stated:
(a) Ambulance services, air and
ground.
(b) Care coordination
services.
(c) Case management
services.
(d) Chiropractic care.
Maintenance visits not covered when no additional progress is apparent or
expected to occur.
(e) Clinic
services and other ambulatory health care services.
(f) Dental benefits:
1. Dental services. Limited to a $1,000
annual benefit maximum per enrollee.
2. Orthodontic services. Limited to a $1,250
lifetime benefit maximum per enrollee. Covered only after a 12-month waiting
period.
(g) Disposable
medical supplies.
(h) Durable
medical equipment and other medically-related or remedial devices:
1. Limited to the most basic equipment that
will provide the needed care.
2.
Hearing aids are limited to one per ear per calendar year up to age 5, and
limited to one per ear every two years thereafter.
(i) Emergency care.
(j) Home health services. Prior approval
required. Limited to 125 visits per enrollee per calendar year.
(k) Hospice care.
(l) Inpatient hospital services, including
rehabilitation hospital services.
(m) Inpatient mental health and substance
abuse services.
(n) Laboratory and
radiological services.
(o)
Outpatient mental health and substance abuse services.
(p) Outpatient services.
(q) Physical therapy, occupational therapy,
and services for individuals with speech, hearing, and language disorders.
Limited to 52 visits per calendar year per type of therapy.
(r) Physician services.
(s) Prenatal care and prepregnancy family
services and supplies.
(t)
Prescription drugs.
(u) Routine
health assessments and immunizations.
(v) Skilled Nursing Facility services.
Limited to 100 days per calendar year following an approved
hospitalization.
(w) Surgical
services.
(x) Vision benefits:
1. Annual vision exam including refractive
exam and glaucoma screening.
2.
Prescription eyeglass lenses. Limited to one pair per calendar year. $85
maximum benefit per pair.
3.
Eyeglass frames. Coverage for replacement frames limited to once every two
calendar years. $100 maximum benefit per pair.
4. Prescription contact lenses in lieu of
eyeglasses. Limited to one pair per calendar year. $150 maximum benefit per
pair.
(2)
Mothers of eligible unborn children who are over age 19 receive all benefits
listed in Paragraph (1), subject to the same limitations and as medically
necessary, except chiropractic services, routine dental services, vision
services, and hearing aids and cochlear implants are not covered for these
enrollees.
(3) Infant Diapers as
defined in Rule
1200-13-13-.01 are covered for
enrollees under age 2, as described in Rule
1200-13-13-.04.
(4) All services covered by CoverKids must be
medically necessary.
(5) An MCO or
DBM may provide non-covered items or services as cost effective alternatives to
covered items or services. Such cost effective alternative services may be
provided because they are either (1) alternatives to covered CoverKids services
that, in the judgment of the MCO or DBM, are cost-effective or (2) preventative
in nature and offered to avoid the development of conditions that, in the
judgment of the MCO or DBM, would require more costly treatment in the future.
Cost effective alternative services are not covered services and are provided
only at the discretion of the MCO or DBM, subject to approval by the Division
of TennCare.
Notes
Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-208, 71-3-1104, 71-3-1106, and 71-3-1110; 42 U.S.C. §§ 1397aa, et seq.; and the Tennessee Title XXI Children's Health Insurance Program State Plan.
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