Section 1200-13-01-.01 - PURPOSE(1) The purpose of this Chapter is to set forth requirements pertaining to the Long-Term Services and Supports (LTSS; formerly and also known as the Long-Term Care or LTC) delivery system.(2) The Bureau of TennCare (Bureau) offers the following LTSS programs and services. Each of these programs is operated in accordance with the authority granted under the Medicaid State Plan or the applicable Waiver authority granted by CMS, and these rules.(a) TennCare CHOICES Program (CHOICES). (See Rule 1200-13-01-.05.) This program has two components: 2. HCBS for the elderly and adults who have Physical Disabilities.(b) Employment and Community First (ECF) CHOICES (See Rule 1200-13-01-.31.)(c) Intermediate Care Facility services for persons with Mental Retardation (or pursuant to federal law, Intermediate Care Facility services for the Mentally Retarded) (ICFs/MR). (See Rule 1200-13-01-.30.)(d) HCBS waivers for individuals with MR. 1. Statewide MR Waiver. (See Rule 1200-13-01-.25.)2. Arlington MR Waiver. (See Rule 1200-13-01-.28.)3. Self-Determination MR Waiver. (See Rule 1200-13-01-.29.)(e) PACE. This is a program for certain dually eligible Medicare and Medicaid beneficiaries that is offered through the Tennessee Medicaid State Plan, Attachment 3.1-A, #26.(3) Individuals receiving LTSS shall be enrolled in Managed Care Contractors (MCCs) as follows: (a) Individuals receiving TennCare-reimbursed LTSS, other than those enrolled in the PACE Program, are also enrolled in a TennCare MCO for primary care, behavioral health services, and acute care services.(b) In addition to enrollment in an MCO, the following LTSS Enrollees, other than those enrolled in the PACE Program, are enrolled with the TennCare Pharmacy Benefits Manager for coverage of prescription drugs:1. Children under the age of twenty-one (21); and2. Adults aged twenty-one (21) and older who are not Medicare beneficiaries.(c) Children under the age of twenty-one (21) who are LTSS Enrollees are also enrolled with the TennCare Dental Benefits Manager (DBM) for coverage of dental services.(4) Acronyms. The following are acronyms used throughout this Chapter and the terms they represent: (a) AAAD - Area Agencies on Aging and Disability(b) ACLF - Assisted Care Living Facility(c) ADL - Activity of Daily Living(d) CBRA - Community-Based Residential Alternative(e) CD - Consumer Direction(f) CEA - Cost Effective Alternative(g) CMS - Centers for Medicare and Medicaid Services(h) DBM - Dental Benefits Manager(i) DD - Developmental Disability(ies)(j) DIDD - Tennessee Department of Intellectual and Developmental Disabilities (formerly known as Tennessee Department of Finance and Administration's Division of Intellectual Disabilities Services or DIDS)(k) DMH - Tennessee Department of Mental Health and Substance Abuse Services (formerly known as the Tennessee Department of Mental Health and Developmental Disabilities)(l) ECF CHOICES - Employment and Community First CHOICES(m) EPSDT - Early and Periodic Screening, Diagnostic, and Treatment(n) EVV - Electronic Visit Verification(o) F&A - Tennessee Department of Finance and Administration(p) FEA - Fiscal Employer Agent(q) FERP - Federal Estate Recovery Program(r) FFS - Fee-for-Service(s) FPL - Federal Poverty Level(t) HCBS - Home and Community Based Services(v) I/DD - Intellectual or Developmental Disability(ies)(w) IADL - Instrumental Activity of Daily Living(x) ICF/IID - Intermediate Care Facility for Individuals with Intellectual Disabilities (formerly and also known as Intermediate Care Facility for persons with Mental Retardation or ICF/MR).(y) ID - Intellectual Disability(ies) (formerly and also known as MR).(aa) LTC - Long-Term Care (also known as LTSS)(bb) LTSS - Long-Term Services and Supports (formerly and also known as LTC)(cc) MCC - Managed Care Contractor(dd) MCO - Managed Care Organization(ff) MR - Mental Retardation (also known as ID)(gg) NF - Nursing Facility(hh) OAA - Operational Administrative Agency(ii) PACE - Program of All-Inclusive Care for the Elderly(jj) PAE - PreAdmission Evaluation(kk) PASRR - PreAdmission Screening and Resident Review(ll) PBM - Pharmacy Benefits Manager(mm) PCSP - Person-Centered Support Plan(nn) PDN - Private Duty Nursing(oo) PERS - Personal Emergency Response System(pp) PNA - Personal Needs Allowance(rr) QIT - Qualifying Income Trust(ss) QMRP - Qualified Mental Retardation Professional(tt) SNF - Skilled Nursing Facility (as defined under Medicare)(uu) SPOE - Single Point of Entry(vv) SSI - Supplemental Security Income(ww) SSI FBR - Supplemental Security Income Federal Benefit Rate(xx) TCAD - Tennessee Commission on Aging and Disability(yy) TPAES - TennCare Pre-Admission Evaluation System(zz) TPL - Third Party Liability.Tenn. Comp. R. & Regs. 1200-13-01-.01
Original rule filed September 10, 1975; effective October 10, 1975. Repealed and refiled July 13, 1977; effective August 12, 1977. Repealed and refiled November 17, 1977; effective December 19, 1977. Amendment filed August 31, 1981; effective October 15, 1981. Amendment filed June 27, 1984; effective July 27, 1984. Amendment filed February 9, 1987; effective April 9, 1987. Amendment filed May 30, 1989; effective July 14, 1989. Amendment filed November 28, 1990; effective January 12, 1991. Amendment filed February 22, 1991; effective April 9, 1991. Amendment filed September 16, 1991; effective October 31, 1991. Amendment filed September 19, 1991; effective November 3, 1991. Amendment filed January 10, 1992; effective February 24, 1992. Amendment filed May 1, 1992; effective June 15, 1992. Amendment filed October 20, 1999; effective January 3, 2000. Amendment filed June 29, 2000; effective September 12, 2000. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendment filed May 27, 2010; effective August 25, 2010. Amendments filed September 26, 2012; effective December 25, 2012. Amendment filed September 26, 2013; effective December 25, 2013. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 30, 2016; effective December 29, 2016. Emergency rules filed November 20, 2020; effective through May 19, 2021. Amendments filed February 17, 2021; effective 5/18/2021.Authority: T.C.A. §§ 4-5-202, 4-5-208, 71-5-105, 71-5-106, 71-5-109, 71-5-110, 71-5-111, 71-5-112, and 71-5-164; TennCare II/III Section 1115(a) Medicaid Demonstration Waiver Extension; and Executive Order No. 11.