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Bureau of TennCare 2009

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Bureau of TennCare 2009. TennCare is Tennessee’s Managed-Care Medicaid Program serving approximately 1.2 million culturally and racially diversified low-income children, pregnant women and disabled Tennesseans, with an annual budget of $7.6 billion. TennCare Enrollment

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Bureau of TennCare


TennCare is Tennessee’s Managed-Care Medicaid Program serving approximately 1.2 million culturally and racially diversified low-income children, pregnant women and disabled Tennesseans, with an annual budget of $7.6 billion.

TennCare Enrollment

Health Care Cultural Competency

MCC Change Schedule

Fraud & Abuse

Long Term Care Community CHOICES Act of 2008

Provider Reminders

tenncare enrollment as of 09 01 09
TennCare Enrollment(As of 09/01/09)

Total Enrollment - 1,143,376

392,999 – East Tennessee

8,668 – Nursing Facility

2,020 – HCBS

358,368 – Middle Tennessee

7,426 – Nursing Facility

1,427 – HCBS

331,415 – West Tennessee

6,240 – Nursing Facility

1,200 - HCBS

60,594 – TennCare Select

166 – Nursing Facility

mco enrollment numbers as of 09 01 09
MCO Enrollment Numbers(As of 09/01/09)

East Tennessee

AmeriChoice 161,255

BlueCare 231,744

Middle Tennessee

AmeriChoice 179,320

AmeriGroup 179,048

West Tennessee

AmeriChoice 150,786

BlueCare 180,629

TennCare Select 60,594

Total Enrollment 1,143,376


Cultural Competency in TennCare

  • 59.1% White
  • 30.7% Black
  • 4.6% Hispanic
  • 5.6% Other
  • Considerations
    • Cultural perspectives
    • Gender
    • Religious or moral preferences
    • Limited English Proficiency

MCC Change Schedule

Starting next year (2010), members will be allowed to change their health plan during one month of the year.

March 2010 West TN Grand Region

May 2010 Middle TN Grand Region

July 2010 East TN Grand Region



Office of Inspector General


FAX: 615-256-3852

Tips can be anonymous

Cash for Tips Policy

  • Tip cannot be anonymous
  • Can claim cash reward if your tip leads to prosecution
  • Details of how program works available at the link above
  • Posters available at TennCare help desk
long term care services carved out of managed care
Long-Term Care Services “Carved Out” of Managed Care

Long-Term Care (LTC) Services have traditionally been carved out of managed care

Nursing Facilities (NFs)

Intermediate Care Facilities for persons with Mental Retardation (ICFs-MR)

Home and Community-Based Services (HCBS) waivers

the long term care community choices act of 2008
The Long-Term Care Community Choices Act of 2008

Passed unanimously by the Tennessee General Assembly

Fundamentally restructures the Medicaid long-term care system for the elderly and adults with physical disabilities in Tennessee


Access to LTC services scattered across different points of entry with no coordination

Nursing Facility Services

Home and Community Based Waiver Services

Home Health and Private Duty Nursing

Difficult for individuals and families to navigate

Fragmented quality strategy, with regulatory focus for Nursing Facility services

limited options
Limited Options

Heavy reliance on Nursing Facilities (NF); home and community options extremely limited

Only one community-based residential alternative to NF care – Assisted Living Facility

Few choices or decision-making opportunity

Few services aimed at preventing or delaying need for more costly care

inefficient use of limited resources
Inefficient Use of Limited Resources

98% of LTC spending for Nursing Facility services

Heavily dependent on most costly services (NF/HH/PDN) even when lower-cost alternatives would better meet needs/desires of individuals and families

Supplants, rather than supports, existing natural support networks of family and other caregivers

Payment systems do not reward efficiency/not based on level of need of persons receiving care

New recurring dollars extremely limited

reorganize the ltc system
Reorganize the LTC system

Simplified access (Single Entry Point)

Streamlined (expedited) enrollment

Comprehensive care coordination across acute/LTC services

Integration of LTC services within existing TennCare managed care delivery system

Continuous quality improvement strategy across acute/LTC continuum

refocus ltc services
Refocus LTC services

Increased use of HCBS

Self-directed care—ability to hire non-traditional providers such as family and friends to provide in-home care

More community-based residential alternatives to Nursing Facility care

rebalance ltc funding
Rebalance LTC funding

Single LTC funding stream (global budget)

Money follows the person into the appropriate, cost-effective setting of their choice

Serve more people with existing LTC funds

More equitable balance of Nursing Facility/HCBS expenditures over time

single point of entry
Single Point of Entry

One access point for new Medicaid applicants seeking access to LTC services – HCBS and Nursing Facility

Public Education and Outreach

Information and Referral

Screening and Assessment

Facilitate eligibility and enrollment

Area Agencies on Aging and Disability (AAADs)

member choice
Member Choice

Members eligible for LTC choose between NF and HCBS (even if HCBS would be more cost-effective)

Members in HCBS must be able to have needs safely met in the community at a cost that does not exceed NF care

Members will be able to choose their Nursing Facility provider

Contracted with the MCO

Able to admit the member

Able to provide the needed services

current ltc services covered under choices
Current LTC Services Covered under CHOICES

Nursing Facility Care

Same HCBS Services Available

Adult Day Care - Assisted Care Living Facility

Assistive Technology - Attendant Care

Home Delivered Meals - Homemaker Services

Personal Care - PERS

Pest Control - Minor Home Modifications

Respite Care (In-Home, In-Patient)

current ltc services covered under choices1
Current LTC Services Covered under CHOICES

Individual Service Limits (HCBS)

Individual Cost Neutrality Cap - Combined cost of all services in home or community setting cannot exceed average cost of NF care

Includes all HCBS

Includes HH/PDN

additional benefits covered under choices
Additional Benefits Covered Under CHOICES

New Community Based Residential Alternatives

Critical Adult Care Homes

24-hour residential care in a homelike environment to no more than 5 elderly or disabled adults

Level II – Specialized and/or Skilled Services for Ventilator Care and Traumatic Brain Injury

Continuum Model – Allows members to age in place

Rules expected to be promulgated by January 2010

Companion Care

Live-in caregiver hired and supervised by the member (consumer direction)

consumer directed options under choices
Consumer Directed Options Under CHOICES

Consumer Direction

Allows consumers to select, direct, and employ their own caregivers

Personal Care

Attendant Care


In-Home Respite

Companion Care

Self Direction of Health Care Tasks

Allows members to direct and supervise a paid personal aide in the performance of health care tasks

Initially limited to administration of oral, topical, and inhaled medications

Limited to consumer directed workers

care coordination in choices
Care Coordination in CHOICES

Comprehensive, continuous, holistic, and person-centered approach to care coordination

Help the member maintain or improve physical or behavioral health status or functional abilities

Maximize member independence

Ensure the member’s health, safety and welfare

Delay or prevent the need for institutional placement

Integrated model of coordination of care –medical as well as social

Addresses physical, behavioral, functional (ADL) and psychosocial needs

Coordinates ALL Medicaid services for the elderly and disabled – physical, behavioral and long term care

care coordination for nursing facility residents
Care Coordination for Nursing Facility Residents

Leverage existing NF Plan of Care

May supplement NF plan of care with additional targeted strategies related to improving health, functional, or quality of life outcomes or to increase and/or maintain functional abilities

Focus on better management of chronic conditions and coordination of services outside the scope of the NF benefit

Assess member potential and interest for transition to community (based on member choice)

Care Coordination Contact Requirements

Quarterly grand rounds

Semi-annual member face-to-face contact

electronic visit verification evv
Electronic Visit Verification (EVV)

EVV System Required for CHOICES

Track the provision of services

Facilitate timely payment

Increased ability to detect and resolve problems

Service gaps

Delays in service delivery

Log-in/Log-out by phone

what happens when choices is implemented
What happens when CHOICES is implemented?

Members receiving NF care will continue to qualify for and receive NF care

Members will be able to stay in the NF where they currently reside, so long as the NF meets CMS conditions of participation

Members are transitioned into CHOICES

LTC Services are provided via CHOICES

LTC Services are NO LONGER provided via the current fee-for-service system

Payment will come from the MCOs

what if nursing facilities don t want to contract with an mco
What if Nursing Facilities don’t want to contract with an MCO?

Nursing Facilities are NOT obligated to contract with each MCO


Existing Medicaid fee-for-service system will no longer exist once CHOICES is implemented

Non-contracted facilities will be reimbursed by MCO for services provided to existing Medicaid/LTC members – but at a lower payment rate than if contracted with the MCO

80% of the lowest rate paid by the MCO to participating network providers for the same service (as set forth in TennCare Rule)

MCOs will seek to admit all new residents to contracted facilities

authorization of nf services
Authorization of NF Services

Immediate authorization of Nursing Facility services for CHOICES members

In accordance with level of nursing facility services approved by TennCare, i.e., TennCare level of care (reimbursement) decision drives prior authorization of NF services

MCO cannot authorize a lesser level or duration of services than approved by TennCare

MCOs will conduct concurrent review of Level II services and may initiate a request to TennCare to reduce when appropriate

nf role in level of care eligibility
NF Role in Level of Care Eligibility

NFs may continue to complete and submit PAEs to TennCare (also hospitals, SPOEs, MCOs)

Level I

Nursing Facility Care

Level II

Skilled Nursing Facility (SNF) Care

TennCare will continue to determine level of care (reimbursement)

choices approval timeline
CHOICES Approval Timeline

May 30, 2008 – LTC CCA passed by General Assembly

July 11, 2008 – CHOICES Concept Paper submitted to CMS

October 2, 2008 – 1115 Waiver Amendment submitted to CMS

June 26, 2009 – Finalized MCO CRA amendment

July 22, 2009 – CMS Terms and Conditions for Approval of 1115 Waiver Amendment

August 2009 – Formal execution of CMS approval for CHOICES

choices implementation
CHOICES Implementation

Phased Implementation

Middle Region – March 1, 2010

East and West Regions to follow – likely first of FY 2011 (July 1, 2010)


Medical Necessity

State law establishes five components (prongs) of medically necessity and the service must satisfy all five components before TennCare will pay for the service. The five components are:

  • It must be recommended by a health care provider
  • It must be required to diagnose or treat the medical condition
  • It must be safe and effective
  • It must not be experimental or investigational
  • It must be the least costly alternative course of diagnosis or treatment that is adequate for the enrollee’s medical condition
provider inquiries
Provider Inquiries

1. Contact “Provider Services” at the MCC

2. Contact your assigned MCC Provider Representative

3. Escalate the complaint to a MCC Managerin the Provider Relations Department

provider inquiries1
Provider Inquiries

4. TennCare Provider Service Department by phoning 1-800-852-2683, and telling them you need to file a MCC provider complaint-Goal of MCC provider complaint system

-Considered “On Request Report”

provider inquiries2
Provider Inquiries
  • Official Provider Complaint Process orIndependent Review Process through Tennessee Department of Commerce & Insurance at
former mcc partners claims
The Bureau of TennCare will NOT accept nor act on requests from providers for reimbursement of claims that would have otherwise been the responsibility of the former MCC Partners

Independent Review Process outlined in T.C.A. 56-32-126 is no longer available

All Independent Review Requests sent to the TN Dept. of Commerce & Insurance (TDCI) will be processed as an official Provider Complaint as long as the company has an active license on file with TDCI

Former MCC Partners Claims
tenncare eligibility verification
There are 2 ways to verify eligibility directly with the Bureau of TennCare:

Call TennCare Provider Services at 800-852-2683

Use the Tennessee Anytime online internet website portal

TennCare Eligibility Verification
retro eligibility
How is someone retro eligible for TennCare?

Most common scenario is someone who gets approved for SSI

In TN, when approved for SSI Disability you are automatically approved for TennCare

Retro Eligibility
mental health only coverage
Formerly known as “State Only” or “Judicial” Members

Effective 1/1/2009 are handled directly by TDMHDD (Tennessee Department of Mental Health & Developmental Disabilities)

Do not have TennCare benefits

Member may be viewable on Tennessee Anytime’s website due to past coverage but will state Not Eligible for TennCare & No MCO on record and No BHO on record

Mental Health Only Coverage
mental health only coverage continued
Eligibility verification and claims are handled by TDMHDD

For additional information:

Mental Health Only Coverage (continued)

TPL Policy

January 1, 2010, an updated TPL policy will become effective.


Provider Communications

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