Section 1200-13-01-.10 - MEDICAL (LEVEL OF CARE) ELIGIBILITY CRITERIA FOR TENNCARE REIMBURSEMENT OF CARE IN NURSING FACILITIES, CHOICES HCBS and PACE(1) Definitions. See Rule 1200-13-01-.02.(2) PreAdmission Evaluations and Discharge/Transfer/Hospice Forms. (a) A PAE is required in the following circumstances:1. When a TennCare Eligible is admitted to a NF for receipt of TennCare-reimbursed NF Services.2. When a private-paying resident of a NF attains TennCare Eligible status.3. When Medicare reimbursement for SNF services has ended and TennCare Level 2 reimbursement for NF services is requested.4. When a NF Eligible is changed from TennCare Level 1 to TennCare Level 2 reimbursement, or from TennCare Level 1 or Level 2 reimbursement to a Chronic Ventilator or Tracheal Suctioning Enhanced Respiratory Care rate, except as specified in Rule 1200-13-01-.10(5)(f).5. When a NF Eligible is changed from TennCare Level 2 reimbursement or an Enhanced Respiratory Care rate to TennCare Level 1 reimbursement, unless the person has an approved unexpired Level 1 PAE.6. When a NF Eligible is changed from an Enhanced Respiratory Care rate to TennCare Level 2 reimbursement, unless the person has an approved unexpired Level 2 PAE.7. When a NF Eligible requires continuation of the same LOC beyond the expiration date assigned by the Bureau.8. When a NF Eligible no longer requires the specific skilled nursing or rehabilitative services for which a Level 2 PAE was approved but requires other skilled nursing or rehabilitative services for which Level 2 reimbursement may be authorized in a NF.9. When a Member enrolled in CHOICES Group 1 or Group 2 on or after July 1, 2012, no longer meets NF LOC and wants to enroll in CHOICES Group 3 for HCBS.10. When a Member enrolled in CHOICES Group 3 (including Interim CHOICES Group 3) on or after July 1, 2012, wants to enroll in CHOICES Group 1 or 2.(b) NFs are required to complete and submit to the Member's MCO a Discharge/Transfer/Hospice Form any time a Member discharges from the facility or stops receiving NF services in the facility, which shall include but is not limited to the following circumstances: 1. When a CHOICES Member transfers from one NF to another such facility.2. When a CHOICES Member discharges to the hospital (even when readmission to the NF is expected following the hospital stay).3. When a CHOICES Member elects to receive hospice services (even if Medicare will be responsible for payment of the hospice benefit).4. When a CHOICES Member discharges home, with or without HCBS. In this case, the NF is obligated to notify the MCO before the Member is discharged from the facility and to coordinate with the MCO in discharge planning in order to ensure that any home and community based services needed by the Member will be available upon discharge, and to avoid a lapse in CHOICES and/or TennCare eligibility.5. Upon the death of a CHOICES Member.(c) A PreAdmission Evaluation is not required in the following circumstances: 1. When a NF Eligible with an approved unexpired Level 1 PAE returns to the NF after being hospitalized.2. When a NF Eligible with an approved unexpired Level 2 PAE returns to the NF after being hospitalized, if there has been no change in the skilled nursing or rehabilitative service for which the PAE was approved.3. When a NF Eligible changes from Level 2 to Level 1 NF reimbursement and has an approved unexpired Level 1 PAE.4. To receive Medicaid co-payment when Medicare is the primary payer of SNF care.5. When a Discharge/Transfer/Hospice Form is appropriate in accordance with (2)(b).6. For authorization by an MCO of Ventilator Weaning services or short-term payment at the Tracheal Suctioning Enhanced Respiratory Care rate for a person who has just been weaned from the ventilator, but who still requires short-term intensive respiratory intervention. Medical necessity determinations and authorization of Ventilator Weaning services and short-term payment at the Tracheal Suctioning Enhanced Respiratory Care rate during the post-weaning period will be managed by the person's MCO.7. When a person will be receiving hospice services in the NF.(d) If a NF admits or allows continued stay of a TennCare Eligible without an approved PAE, it does so at its own risk and in such event the NF shall give the Applicant a plain language written notice, in a format approved by the Bureau, that Medicaid reimbursement will not be paid unless the PAE is approved and if it is not finally approved the Applicant can be held financially liable for services provided, including services delivered prior to the effective date of the PAE and enrollment in CHOICES Group 1, unless a third party is liable.(e) Except as specified in 1200-13-01-.10(2)(e) 2., an approved PAE is valid for ninety (90) calendar days beginning with the PAE Approval Date, unless an earlier expiration date has been established by TennCare (see 1200-13-01-.10(2)(h)). A valid approved PAE that has not been used within ninety (90) calendar days of the PAE Approval Date must be updated before it can be used. For purposes of Medicaid-reimbursed NF services, such update may be completed only upon submission of a confirmed Medicaid Only Payer Date. To update the PAE, the physician (in the case of NF services) or a Qualified Assessor (in the case of HCBS) shall certify that the Applicant's medical condition on the revised PAE Request Date is consistent with that described in the initial certification and/or assessment and that NF services, or alternative HCBS, as applicable, are medically necessary for the Applicant. If the Applicant's medical condition has significantly changed such that the previously approved PAE does not reasonably reflect the Applicant's current medical condition and functional capabilities, a new PAE shall be required.1. A PAE that is not used within 365 days of the PAE Approval Date shall expire and shall not be updated.2. A PAE shall also expire upon the person's discharge from a NF, unless: (i) The person transfers to another NF.(ii) The person is discharged to the hospital and returns directly to the NF or to another NF.(iii) The person is discharged home for therapeutic leave and returns to the NF within no more than ten (10) days.(iv) The person is discharged home and a request to transition to CHOICES Group 2 is submitted by the MCO and approved by TennCare prior to the person's discharge from the NF.3. For persons electing hospice: (i) If a person receiving NF services elects to receive hospice, is disenrolled from CHOICES Group 1, and subsequently withdraws the hospice election and wishes to re-enroll in CHOICES Group 1, the approved PAE may be used so long as: (I) The person has remained in the NF;(II) The person's condition has not changed;(III) No more than thirty (30) days have lapsed since the person's disenrollment from CHOICES Group 1; and(IV) NF LOC criteria have not changed.(ii) If the person's condition has changed or if more than thirty (30) days have lapsed since the person's disenrollment from CHOICES Group 1, a new PAE shall be required.(iii) If the PAE effective date was prior to July 1, 2012, a new PAE must be submitted and the person must qualify based on the new NF LOC criteria in place as of July 1, 2012.(f) A PAE must include a recent history and physical or current medical records that support the Applicant's functional and/or skilled nursing or rehabilitative needs, as reflected in the PAE. A history and physical performed within 365 calendar days of the PAE Request Date may be used if the Applicant's condition has not significantly changed. Medical records (progress notes, office records, discharge summaries, etc.) may be used to supplement a history and physical and provide current medical information if changes have occurred since the history and physical was performed, or may be used in lieu of a history and physical, so long as the records provide medical evidence sufficient to support the functional and/or skilled or rehabilitative needs reflected in the PAE.(g) A PAE must be certified as follows:1. Physician certification shall be required for reimbursement of NF services and enrollment into CHOICES Group 1. Consistent with requirements pertaining to certification of the need for SNF care set forth at 42 CFR § 424.20 and in Section 3108 of the Affordable Care Act, certification of the need for NF care may be performed by a nurse practitioner, clinical nurse specialist, or physician assistant, none of whom has a direct or indirect employment relationship with the facility but who is working in collaboration with a physician.2. Certification of the level of care assessment by a Qualified Assessor shall be required for all PAEs.(h) A PAE may be approved by the Bureau for a fixed period of time with an expiration date based on an assessment by the Bureau of the Applicant's medical condition and anticipated continuing need for inpatient nursing care. Notice of appeal rights shall be provided when a PAE is approved with an expiration date.(i) PASRR. 1. All Applicants who reside in or seek admission to a Medicaid-certified NF must have a PASRR Level I screen for mental illness and mental retardation. The initial Level I screen must be completed prior to admission to the NF and submitted to TennCare regardless of: (ii) Whether the PASRR screening is positive or negative (including specified exemptions); and(iii) The level of NF reimbursement requested.2. If the Level I screen indicates the need for a PASRR Level II evaluation of need for specialized services for mental illness and/or mental retardation, the Applicant must undergo the PASRR Level II evaluation prior to admission to the NF.(j) Medicaid payment will not be available for any dates of NF services rendered prior to the date the PASRR process is complete and the Applicant has been determined appropriate for nursing home placement. The PASRR process is complete when either: 1. TennCare has received a negative Level I PASRR screen form and no contradictory information is subsequently received; or2. For Applicants with a positive Level I PASRR screen (as submitted or upon review and determination by the Bureau), the Bureau has received a certified exemption or advance categorical determination signed by the physician; or a determination by DMH and/or DIDD, as applicable, that the Applicant is appropriate for NF placement. Determination by the Bureau that a Level II PASRR evaluation must be performed may be made:(i) Upon receipt of a positive PASRR screen from the NF or other submitting entity;(ii) Based on TennCare review of a negative PASRR screening form or history and physical submitted by a NF or other entity; or(iii) Upon review of any contradictory information submitted in the PAE application or supporting documentation at any time prior to disposition of the PAE.(k) A NF that has entered into a provider agreement with a TennCare MCO shall assist a NF resident or Applicant as follows:1. The NF shall assist a NF resident or an Applicant for admission in applying for Medicaid eligibility and in applying for Medicaid-reimbursed NF care. This shall include assistance in properly completing all necessary paperwork and in providing relevant NF documentation to support the PAE. For Applicants not currently eligible for Medicaid, the NF may request assistance from the AAAD in completing the Medicaid application process in order to expedite the eligibility determination by DHS. Reasonable accommodations shall be made for an Applicant with disabilities or, alternatively, for a Designated Correspondent with disabilities when assistance is needed with the proper completion and submission of a PAE.2. The NF shall request a Notice of Disposition or Change from the Department of Human Services upon learning that a resident or Applicant has, or is likely to have, applied for Medicaid eligibility.(l) The Bureau shall process PAEs independently of determinations of Medicaid eligibility by DHS; however, Medicaid reimbursement for NF care shall not be available until the PASRR process has been completed, and both the PAE and financial eligibility have been approved.(3) Medicaid Reimbursement.(a) A NF that has entered into a provider agreement with a TennCare MCO is entitled to receive Medicaid reimbursement for covered services provided to a NF Eligible if: 1. The NF has completed the PASRR process as described in 1200-13-01-.10(2)(i) above and pursuant to 1200-13-01-.23.2. The Bureau has received an approvable PAE for the person within ten (10) calendar days of the PAE Request Date or the physician certification date, whichever is earlier. The PAE Approval Date shall not be more than ten (10) days prior to date of submission of an approvable PAE. An approvable PAE is one in which any deficiencies in the submitted application are cured prior to disposition of the PAE.3. The NF has entered into the TennCare PreAdmission Evaluation System (TPAES) a Medicaid Only Payer Date.4. The person has been enrolled into CHOICES Group 1.5. For a retroactive eligibility determination, the Bureau has received a Notice of Disposition or Change and has received an approvable request to update an approved, unexpired PAE within thirty (30) calendar days of the mailing date of the Notice of Disposition or Change, so long as the person has remained in a NF since the PAE was completed (except for short-term hospitalization). The effective date of payment for NF services shall not be earlier than the PAE Approval Date of the original approved, unexpired PAE that has been updated.6. If the NF participates in the Enrollee's MCO, reimbursement will be made by the MCO to the NF as a Network Provider. If the NF does not participate in the Enrollee's MCO, reimbursement will be made by the MCO to the NF as a non-participating provider, in accordance with Rule 1200-13-01-.05(10).(b) Any deficiencies in a submitted PAE application must be cured prior to disposition of the PAE to preserve the PAE submission date for payment purposes. 1. Deficiencies cured after the PAE is denied but within thirty (30) days of the original PAE submission date will be processed as a new application, with reconsideration of the earlier denial based on the record as a whole (including both the original denied application and the additional information submitted). If approved, the effective date of PAE approval can be no more than ten (10) days prior to the date of receipt of the information which cured the original deficiencies in the denied PAE. Payment will not be retroactive back to the date the deficient application was received or to the date requested in the deficient application.2. Once a PAE has been denied, the original denied PAE application must be resubmitted along with any additional information which cures the deficiencies of the original application. Failure to include the original denied application may delay the availability of Medicaid reimbursement for NF services.(c) The earliest date of Medicaid reimbursement for care provided in a NF shall be the date that all of the following criteria are met:1. Completion of the PASRR process, as described in 1200-13-01-.10(2)(i) above and pursuant to 1200-13-01-.23;2. The effective date of level of care eligibility as reflected by the PAE Approval Date;3. The effective date of Medicaid eligibility;4. The date of admission to the NF; and5. The effective date of enrollment into CHOICES Group 1.(d) Application of new LOC criteria. The new LOC criteria set forth in 1200-13-01-.10(4) shall be applied to all Applicants enrolled into CHOICES on or after July 1, 2012, based on their effective date of enrollment into the CHOICES program. 1. It is the date of enrollment into CHOICES and not the date of PAE submission, approval, or the PAE effective date which determines the LOC criteria that must be applied.2. TennCare may review a PAE that had been reviewed and approved based on the NF LOC criteria in place as of June 30, 2012, to determine whether an Applicant who will be enrolled into CHOICES on or after July 1, 2012, meets the new LOC criteria. However, all Applicants enrolled into CHOICES with an effective date of enrollment on or after July 1, 2012, shall meet the criteria in place at the time of enrollment, and in accordance with these rules.(e) A NF that has entered into a provider agreement with a TennCare MCO and that admits a TennCare Eligible without completion of the PASRR process and without an approved PAE does so without the assurance of Medicaid reimbursement.(f) TennCare reimbursement will only be made to a NF on behalf of the NF Eligible and not directly to the NF Eligible.(g) A NF that has entered into a provider agreement with a TennCare MCO shall admit persons on a first come, first served basis, except as otherwise permitted by State and federal laws and regulations.(4) Level of Care Criteria for Medicaid Level 1 Reimbursement of Care in a Nursing Facility, CHOICES HCBS, ECF CHOICES HCBS and PACE.(a) The NF must have completed the PASRR process, as applicable and as described in 1200-13-01-.10(2)(i) above and pursuant to 1200-13-01-.23.(b) An Applicant must meet both of the following LOC criteria in order to be approved for TennCare-reimbursed care in a NF, CHOICES HCBS, ECF CHOICES HCBS or PACE, as applicable: 1. Medical Necessity of Care: (i) Applicants requesting TennCare-reimbursed NF care. Care in a NF must be expected to improve or ameliorate the Applicant's physical or mental condition, to prevent a deterioration in health status, or to delay progression of a disease or disability, and such care must be ordered and supervised by a physician on an ongoing basis.(ii) Applicants requesting HCBS in CHOICES, ECF CHOICES or PACE. HCBS must be required in order to allow the Applicant to continue living safely in the home or community-based setting and to prevent or delay placement in a NF, and such HCBS must be specified in an approved plan of care and needed on an ongoing basis.(I) The need for one-time CHOICES HCBS or one-time ECF CHOICES HCBS is not sufficient to meet medical necessity of care for HCBS.(II) If a Member's ongoing need for assistance with activities of daily living and/or instrumental activities of daily living can be met, as determined through the needs assessment and care planning processes, through the provision of assistance by family members and/or other caregivers, or through the receipt of services available to the Member through community resources (e.g., Meals on Wheels) or other payer sources (e.g., Medicare), the Member does not require HCBS in order to continue living safely in the home and community-based setting and to prevent or delay placement in a NF.2. Need for Inpatient Nursing Care: (i) Applicants requesting TennCare-reimbursed NF care. The Applicant must have a physical or mental condition, disability, or impairment that, as a practical matter, requires daily inpatient nursing care. The Applicant must be unable to self-perform needed nursing care and must meet one (1) or more of the following criteria on an ongoing basis:
(I) Have a total score of at least nine (9) on the TennCare NF LOC Acuity Scale; or(II) Meet one (1) or more of the ADL or related criteria specified in 1200-13-01-.10(4)(b) 2.(iii) on an ongoing basis and be determined by TennCare through approval of a Safety Determination Request to not be able to be safely served within the array of services and supports that would be available if the Applicant was enrolled in CHOICES Group 3, including CHOICES HCBS up to the Expenditure Cap, non-CHOICES HCBS available through TennCare (e.g., home health), cost-effective alternative services (as applicable), services available through Medicare, private insurance or other funding sources, and natural supports provided by family members and other caregivers who are willing and able to provide such care. An Applicant who cannot be safely served in CHOICES Group 3 does not qualify to enroll in CHOICES Group 3. An applicant who could be safely served in CHOICES Group 3 except that he does not meet Medicaid categorical and financial eligibility criteria for CHOICES Group 3 (i.e. is not an SSI recipient) shall not be eligible for CHOICES Group 1 as a result of a Safety Determination.(ii) Applicants eligible to receive care in a NF, but requesting HCBS in CHOICES Group 2, ECF CHOICES or PACE. The Applicant must have a physical or mental condition, disability, or impairment that requires ongoing supervision and/or assistance with activities of daily living in the home or community setting. In the absence of ongoing CHOICES HCBS, ECF CHOICES HCBS or PACE, the Applicant would require and must qualify to receive NF services in order to remain eligible for HCBS. The Applicant must be unable to self-perform needed nursing care and must meet one (1) or more of the following criteria on an ongoing basis:
(I) Have a total score of at least nine (9) on the TennCare NF LOC Acuity Scale; or(II) For a CHOICES Group 2 Applicant, meet one (1) or more of the ADL or related criteria specified in 1200-13-01-.10(4)(b) 2.(iii) on an ongoing basis and be determined by TennCare through approval of a Safety Determination Request to not be able to be safely served within the array of services and supports that would be available if the Applicant was enrolled in CHOICES Group 3, including CHOICES HCBS up to the Expenditure Cap, non-CHOICES HCBS available through TennCare (e.g., home health), cost-effective alternative services (as applicable), services available through Medicare, private insurance or other funding sources, and natural supports provided by family members and other caregivers who are willing and able to provide such care. An Applicant who cannot be safely served in CHOICES Group 3 does not qualify to enroll in CHOICES Group 3. An applicant who could be safely served in CHOICES Group 3 except that he does not meet Medicaid categorical and financial eligibility criteria for CHOICES Group 3 (i.e. is not an SSI recipient) shall not be eligible for CHOICES Group 2 as a result of a Safety Determination; or(III) For an ECF CHOICES Applicant age twenty-one (21) or older, have an intellectual or developmental disability and be determined through approval of a Safety Determination Request to not be able to be safely served within the array of services and supports that would be available if the Applicant was enrolled in ECF CHOICES Group 5, including ECF CHOICES HCBS up to the Expenditure Cap; one-time emergency assistance up to $6,000; non-ECF CHOICES HCBS available through TennCare (e.g., home health); cost-effective alternative services (as applicable); services available through Medicare, private insurance or other funding sources; and natural supports provided by family members and other caregivers who are willing and able to provide such care.(iii) Applicants not eligible to receive care in a NF, but at risk of NF placement and requesting HCBS in CHOICES Group 3, including Interim CHOICES Group 3.The Applicant must have a physical or mental condition, disability, or impairment that requires ongoing supervision and/or assistance with activities of daily living in the home or community setting. In the absence of ongoing CHOICES HCBS, the Applicant would not be able to live safely in the community and would be at risk of NF placement. The following criteria shall reflect the individual's Applicant's capabilities on an ongoing basis and not isolated, exceptional, or infrequent limitations of function in a generally independent person who is able to function with minimal supervision or assistance. The Applicant must be unable to self-perform needed nursing care and must meet one (1) or more of the following criteria on an ongoing basis: (I) Transfer. The Applicant is incapable of transfer to and from bed, chair, or toilet unless physical assistance is provided by others on an ongoing basis (daily or at least four days per week). Approval of this deficit shall require documentation of the medical condition(s) contributing to this deficit, as well as the specific type and frequency of transfer assistance required.(II) Mobility. The Applicant requires physical assistance from another person for mobility on an ongoing basis (daily or at least four days per week). Mobility is defined as the ability to walk, using mobility aids such as a walker, crutch, or cane if required, or the ability to use a wheelchair (manual or electric) if walking is not feasible. The need for a wheelchair, walker, crutch, cane, or other mobility aid shall not by itself be considered to meet this requirement. Approval of this deficit shall require documentation of the medical condition(s) contributing to this deficit, as well as the specific type and frequency of mobility assistance required.(III) Eating. The Applicant requires physical assistance with gastrostomy tube feedings or physical assistance or constant one-on-one observation and verbal assistance (reminding, encouraging) 4 or more days per week to consume prepared food and drink (or self-administer tube feedings, as applicable) or must be fed part or all of each meal. Food preparation, tray set-up, assistance in cutting up foods, and general supervision of multiple residents shall not be considered to meet this requirement. Approval of this deficit shall require documentation which supports the need for such intervention, along with evidence that in the absence of such physical assistance or constant one-on-one observation and verbal assistance, the Applicant would be unable to self-perform this task. For PAEs submitted by the AAAD (or entity other than an MCO, NF, or PACE Organization), an eating or feeding plan specifying the type, frequency and duration of supports required by the Applicant for feeding, along with evidence that in the absence of such physical assistance or constant one-on-one observation and verbal assistance, the Applicant would be unable to self-perform this task shall be required.(IV) Toileting. The Applicant requires physical assistance from another person to use the toilet or to perform incontinence care, ostomy care, or catheter care on an ongoing basis (daily or at least four days per week). Approval of this deficit shall require documentation of the specific type and frequency of toileting assistance required.(V) Expressive and Receptive Communication. The Applicant is incapable of reliably communicating basic needs and wants (e.g., need for assistance with toileting; presence of pain) in a manner that can be understood by others, including through the use of assistive devices; or the Applicant is incapable of underst anding and following very simple instructions and comm ands without continual intervention (daily or at least four days per week). Approval of this deficit shall require documentation of the medical condition(s) contributing to this deficit, as well as the specific type and frequency of communication assistance required.(VI) Orientation. The Applicant is disoriented to person (e.g., fails to remember own name, or recognize immediate family members), place (e.g., does not know residence is a NF), or event/situation (e.g., is unaware of current circumstances in order to make decisions that prevent risk of harm) daily or at least four days per week. Approval of this deficit shall require documentation of the specific orientation deficit(s), including the frequency of occurrence of such deficit(s), and the impact of such deficit(s) on the Applicant.(VII) Medication Administration. The Applicant is not cognitively or physically capable (daily or at least four days per week) of self-administering prescribed medications at the prescribed schedule despite the availability of limited assistance from another person. Limited assistance includes, but is not limited to, reminding when to take medications, encouragement to take, reading medication labels, opening bottles, h anding to Applicant, reassurance of the correct dose, and the use of assistive devices including a prepared medication box. An occasional lapse in adherence to a medication schedule shall not be sufficient for approval of this deficit; the Applicant must have physical or cognitive impairments which persistently inhibit his or her ability to self-administer medications. Approval of this deficit shall require evidence that such interventions have been tried or would not be successful, and that in the absence of intervention, the Applicant's health would be at serious and imminent risk of harm.(VIII) Behavior. The Applicant requires persistent staff or caregiver intervention and supervision (daily or at least four days per week) due to an established and persistent pattern of behavioral problems which are not primarily related to a mental health condition (for which mental health treatment would be the most appropriate course of treatment) or a substance abuse disorder (for which substance abuse treatment would be the most appropriate course of treatment), and which, absent such continual intervention and supervision, place the Applicant or others at imminent and serious risk of harm. Such behaviors may include physical aggression (including assaultive or self-injurious behavior, destruction of property, resistive or combative to personal and other care, intimidating/threatening, or sexual acting out or exploitation) or inappropriate or unsafe behavior (including disrobing in public, eating non-edible substances, fire setting, unsafe cooking or smoking, w andering, elopement, or getting lost). Approval of this deficit shall require documentation of the specific behaviors and the frequency of such behaviors.(IX) Skilled Nursing or Rehabilitative Services. The Applicant requires daily skilled nursing or rehabilitative services at a greater frequency, duration, or intensity than, for practical purposes, would be provided through daily home health visits. Approval of such skilled nursing or rehabilitative services shall require a physician's order and other documentation as specified in the PAE. Level 2 reimbursement for rehabilitative services and acuity points for such rehabilitative services shall not be approved for chronic conditions, exacerbations of chronic conditions, weakness after hospitalization, or maintenance of functional status, although the NF shall be required to ensure that appropriate services and supports are provided based on the individualized needs of each resident.(iv) Applicants not eligible to receive care in a NF, but at risk of NF placement and requesting HCBS in ECF CHOICES Group 4 or 5. The Applicant has an intellectual or developmental disability as defined under Tennessee state law, including for an Applicant with ID, limitations in two (2) or more adaptive skill areas (i.e., communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work); and for an Applicant age five (5) or older with DD, substantial functional limitations in three (3) or more major life activities (i.e., self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; and economic self-sufficiency); such that, in the absence of the provision of a moderate level of ECF CHOICES home and community based services and supports on an ongoing basis, the individual's condition and/or ability to continue living in the community will likely deteriorate, resulting in the need for more expensive institutional placement.(c) For continued TennCare reimbursement of care in a NF, a Member must continue to be financially eligible for TennCare reimbursement for NF care and must continue to meet NF LOC (including medical necessity of care and the need for inpatient care) in place at the time of enrollment into CHOICES Group 1.(d) A NF Eligible admitted to a NF and enrolled in CHOICES Group 1 prior to July 1, 2012, who continues to meet the LOC criteria in place at the time of enrollment into CHOICES Group 1 shall continue to meet NF LOC for purposes of enrolling in CHOICES Group 2, subject to requirements set forth in 1200-13-01-.05(3) and 1200-13-01-.05(4).(e) A NF Eligible receiving HCBS in CHOICES Group 2 prior to July 1, 2012, shall be required to meet the NF LOC in place as of July 1, 2012, in order to qualify for Medicaid-reimbursed NF care unless TennCare determines that the Member's needs can no longer be safely and cost-effectively met in CHOICES Group 2.(5) Criteria for Medicaid Level 2 and Enhanced Respiratory Care Reimbursement of Care in a NF. (a) The NF must have completed the PASRR process as described in 1200-13-01-.10(2)(i) above and pursuant to 1200-13-01-.23.(b) An Applicant must meet both of the following criteria in order to be approved for Medicaid Level 2 reimbursement of care in a NF:1. The Applicant must meet NF LOC as defined in 1200-13-01-.10(4) above.2. Need for Inpatient Skilled Nursing or Rehabilitative Services on a Daily Basis: The Applicant must have a physical or mental condition, disability, or impairment that requires skilled nursing or rehabilitative services on a daily basis or skilled rehabilitative services at least five days per week when skilled rehabilitative services constitute the primary basis for the approval of the PAE. The Applicant must require such services at a greater frequency, duration, or intensity than, for practical purposes, would be provided through a daily home health visit. In addition, the Applicant must be mentally or physically unable to perform the needed skilled services or the Applicant must require skilled services which, in accordance with accepted medical practice, are not usually and customarily self-performed. For interpretation of this rule, the following shall apply: (i) Administration of oral medications, ophthalmics, otics, inhalers, subcutaneous injections (e.g., fixed-dose insulin, subtherapeutic heparin, and calcitonin), topicals, suppositories, nebulizer treatments, oxygen administration, shall not, in and of itself, be considered sufficient to meet the requirement of (5)(b)2.(ii) Nursing observation and assessment, in and of itself, shall not be considered sufficient to meet the requirement of (5)(b)2. Examples of nursing services for which Level 2 reimbursement might be provided include, but are not limited to, the following: (I) Gastrostomy tube feeding(II) Sterile dressings for Stage 3 or 4 pressure sores(III) Total parenteral nutrition(IV) Intravenous fluid administration(V) Nasopharyngeal and tracheostomy suctioning(iii) A skilled rehabilitative service must be expected to improve the Applicant's condition. Restorative and maintenance nursing procedures (e.g., routine range of motion exercises; st and-by assistance during ambulation; applications of splints/braces by nurses and nurses' aides) shall not be considered sufficient to fulfill the requirement of (5)(b)2. Factors to be considered in the decision as to whether a rehabilitative service meets, or continues to meet, the requirement of (5)(b)2. shall include, but not be limited to, an assessment of the type of therapy and its frequency, the remoteness of the injury or impairment, and the reasonable potential for improvement in the Applicant's functional capabilities or medical condition.(iv) Effective July 1, 2012, level 2 NF reimbursement for sliding scale insulin may be authorized for an initial period of no more than two (2) weeks for Applicants with unstable blood glucose levels that require daily monitoring and administration of sliding scale insulin. Approval of such reimbursement will require a physician's order and supporting documentation including a plan of care for stabilizing the Applicant's blood sugar and transitioning to fixed dosing during the approval period. Additional periods of no more than two (2) weeks per period, not to exceed a maximum total of sixty (60) days, may be authorized upon submission of a new PAE and only with a physician's order and detailed explanation regarding why previous efforts to stabilize and transition to fixed dosing were not successful.(c) In order to be approved for TennCare-reimbursed care in a NF at the Chronic Ventilator rate of reimbursement, an Applicant must be ventilator dependent for at least 12 hours each day with an invasive patient end of the circuit (i.e., tracheostomy cannula). On a case-by-case basis, TennCare may, subject to additional medical review, authorize Chronic Ventilator Reimbursement for an Applicant who is ventilator dependent with a progressive neuromuscular disorder or spinal cord injury, and is ventilated using noninvasive positive pressure ventilation (NIPPV) by mask or mouthpiece for at least 12 hours each day in order to avoid or delay tracheostomy.(d) In order to be approved by the Bureau for TennCare-reimbursed care in a NF at the Secretion Management Tracheal Suctioning rate of reimbursement: 1. An Applicant must have a functioning tracheostomy and a copious volume of secretions, and require either: (i) Invasive tracheal suctioning, at a minimum, once every three (3) hours with documented assessment pre- and post-suctioning; or(ii) The use of mechanical airway clearance devices and/or heated high flow molecular humidification via the tracheostomy, at a minimum, three (3) times per day with documented assessment pre- and post.(I) A copious volume of secretions shall be defined as 25 to 30 ml per day occurring over the course of the day, and not necessarily at every suctioning.(II) The requirement for invasive tracheal suctioning, at a minimum, once every three (3) hours shall be applied as a marker of the severity of the Applicant's respiratory care needs. Secretion Management Tracheal Suctioning is not a scheduled intervention and shall not be performed as a medication would be delivered, i.e., at scheduled intervals (except as prescribed by an appropriately licensed health care professional practicing within the scope of his or her license). Rather, tracheal suctioning should be provided as clinically indicated, based on the needs of each person requiring such care; evidence of the need should be clearly and accurately documented. This could mean a shorter or longer interval at any point, but with a clinical need for invasive tracheal suctioning an average of every three (3) hours or more often in order to qualify for Secretion Management Tracheal Suctioning Reimbursement, except when mechanical airway clearance devices and/or heated high flow molecular humidification via the tracheostomy are used to manage secretions.(III) When mechanical airway clearance devices and/or heated high flow molecular humidification via the tracheostomy are used to manage secretions, there must be documented evidence of the Applicant's copious secretions, but they are managed non-invasively using a cough assist device periodically or high flow molecular humidity continuously or at least three (3) times per day as ongoing treatment. The device is expected to provide ongoing relief of the copious volume of secretions, which shall not negate the need for intervention (and eligibility for Secretion Management Tracheal Suctioning Reimbursement), if absent the high flow device, the copious volume of secretions would require more invasive management.2. The suctioning (or airway clearance, as applicable) must be required to remove excess secretions and/or aspirate from the trachea, which cannot be removed by the Applicant's spontaneous effort. Suctioning of the nasal or oral cavity does not qualify for this higher level of reimbursement. An MCO may authorize, based on medical necessity, short-term payment at the Sub-Acute Tracheal Suctioning Enhanced Respiratory Care rate for a person who has just been weaned from the ventilator, but who still requires short-term intensive respiratory intervention during the post-weaning period which shall include documented progress in weaning from the tracheostomy.3. A PAE for Secretion Management Tracheal Suctioning Reimbursement shall be approved for no more than a period of thirty (30) days. Clinical review and approval of a new PAE shall be required for ongoing coverage, which shall include evaluation of clinical progress and the NF's efforts to improve secretion management through alternative methods. TennCare may, on a case-by-case basis, approve a PAE for Secretion Management Tracheal Suctioning Management Reimbursement for a period of more than thirty (30) days, e.g., if a person has ALS (amyotrophic lateral sclerosis) or another progressive neuromuscular disorder, spinal cord injury, or chronic respiratory failure, or is in a persistent vegetative state, and evidence clearly supports that ongoing secretion management tracheal suctioning is expected to continue.4. A NF who has an approved PAE for Tracheal Suctioning Reimbursement for any resident as of July 1, 2016 shall be entitled to continue to receive such level of reimbursement no later than July 31, 2016 (or any earlier date that may be specified in the approved PAE). The NF shall submit a new PAE for such resident no later than July 19, 2016 in order to determine whether Secretion Management Tracheal Suctioning Reimbursement will be continued, or whether a different level of NF reimbursement is appropriate.(e) Determination of medical necessity and authorization for Ventilator Weaning Reimbursement, or short-term payment at the Sub-Acute Tracheal Suctioning Enhanced Respiratory Care rate for a person who has just been weaned from the ventilator, but who still requires short-term intensive respiratory intervention shall be managed by the Enrollee's MCO.(6) TennCare Nursing Facility Level of Care Acuity Scale. (a) Effective July 1, 2012, for all new enrollments into CHOICES Groups 1 and 2 and for approval of NF LOC for individuals applying for enrollment into ECF CHOICES, LOC eligibility for TennCare-reimbursement of NF services shall be based on an assessment of the following measures:1. The Applicant's need for assistance with the following Activities of Daily Living (ADLs): 2. The Applicant's level of independence (or deficiency) in the following ADL-related functions: (i) Communication (expressive and receptive);(ii) Orientation (to person and place);(iii) Dementia-related behaviors; and(iv) Self-administration of medications.3. The Applicant's need for certain skilled and/or rehabilitative services.(b) One or more questions on the PAE for NF LOC shall be used to assess each of the ADL or related measures specified above. There are four (4) possible responses to each question.(c) Weighted Values. 1. Interpretation of possible responses for all measures except behavior:(i) "Always" shall mean that the Applicant is always independent with that ADL or related activity.(ii) "Usually" shall mean that the Applicant is usually independent (requiring assistance fewer than 4 days per week).(iii) "Usually not" shall mean that the Applicant is usually not independent (requiring assistance 4 or more days per week).(iv) "Never" means that the Applicant is never independent with that ADL or related activity.2. Interpretation of possible responses for the behavior measure: (i) "Always" shall mean that the Applicant always requires intervention for dementia-related behaviors.(ii) "Usually" shall mean that the Applicant requires intervention for dementia-related behaviors 4 or more days per week.(iii) "Usually not" shall mean that the Applicant requires intervention for dementia-related behaviors, but fewer than 4 days per week.(iv) "Never" shall mean that the Applicant does not have dementia-related behaviors that require intervention.3. The weighted value of each of the potential responses to a question regarding the ADL or related functions specified above when supported by the medical evidence submitted with the PAE shall be as follows: ADL (or related) question | Condition | Always | Usually | Usually not | Never | Maximum Individual Acuity Score | Maximum Acuity Score for the Measure(s) |
Transfer | Highest value of two measures | 0 | 1 | 3 | 4 | 4 | |
Mobility | 0 | 1 | 2 | 3 | 3 | 4 |
Eating | | 0 | 1 | 3 | 4 | 4 | 4 |
Toileting | | 0 | 0 | 1 | 2 | 2 | 3 |
Incontinence care | Highest value of three questions for the toileting measure | 0 | 1 | 2 | 3 | 3 |
Catheter/ostomy care | 0 | 1 | 2 | 3 | 3 |
Orientation | | 0 | 1 | 3 | 4 | 4 | 4 |
Expressive communication | Highest value of two questions for the communication measure | 0 | 0 | 0 | 1 | 1 | 1 |
Receptive communication | 0 | 0 | 0 | 1 | 1 |
Self-administration of medication | First question only; excludes SS insulin | 0 | 0 | 1 | 2 | 2 | 2 |
Behavior | | 3 | 2 | 1 | 0 | 3 | 3 |
Maximum possible | ADL (or related) Acuity | Score | | | | | 21 |
4. The weighted value for each of the skilled and/or rehabilitative services for which level 2 or enhanced respiratory care NF reimbursement could be authorized when determined by TennCare to be needed by the Applicant on a daily basis or at least five days per week for rehabilitative services, based on the medical evidence submitted with the PAE shall be as follows: Skilled or rehabilitative service | Maximum Individual Acuity Score |
Ventilator | 5 |
Frequent tracheal suctioning | 4 |
New tracheostomy or old tracheostomy requiring suctioning through the tracheostomy multiple times per day at less frequent intervals, i.e., < every 4 hours | 3 |
Total Perenteral Nutrition (TPN) | 3 |
Complex wound care (i.e., infected or dehisced wounds) | 3 |
Wound care for stage 3 or 4 decubitus | 2 |
Peritoneal dialysis | 2 |
Tube feeding, enteral | 2 |
Intravenous fluid administration | 1 |
Injections, sliding scale insulin | 1 |
Injections, other IV, IM | 1 |
Isolation precautions | 1 |
PCA pump | 1 |
Occupational Therapy by OT or OT assistant | 1 |
Physical Therapy by PT or PT assistant | 1 |
Teaching catheter/ostomy care | 0 |
Teaching self-injection | 0 |
Other | 0 |
Maximum Possible Skilled Services Acuity Score | 5 |
5. Conditions.(i) Maximum Acuity Score for Transfer and Mobility:(I) Assessment of the need for assistance with transfer and the need for assistance with mobility are separate but overlapping measures of an Applicant's physical independence (or dependence) with movement.(II) The maximum individual acuity score for transfer shall be four (4).(III) The maximum individual acuity score for mobility shall be three (3).(IV) The highest individual acuity score among the transfer and mobility measures shall be the Applicant's total acuity score across both measures.(V) The maximum acuity score across both of the transfer and mobility measures shall be four (4).(ii) Maximum Acuity Score for Toileting: (I) Assessment of the need for assistance with toileting shall include the following:I. An assessment of the Applicant's need for assistance with toileting;II. Whether the Applicant is incontinent, and if so, the degree to which the Applicant is independent in incontinence care; andIII. Whether the Applicant requires a catheter and/or ostomy, and if so, the degree to which the Applicant is independent with catheter and/or ostomy care.(II) The highest individual acuity score among each of the three (3) toileting questions shall be the Applicant's total acuity score for the toileting measure.(III) The maximum acuity score for toileting shall be two (2).(iii) Maximum Acuity Score for Communication: (I) Assessment of the Applicant's level of independence (or deficiency) with communication shall include an assessment of expressive as well as receptive communication.(II) The highest individual acuity score across each of the two (2) communication questions shall be the Applicant's total score for the communication measure.(III) The maximum possible acuity score for communication shall be one (1).(iv) Maximum Acuity Score for Self-Administration of Medication:(I) Assessment of the Applicant's level of independence (or deficiency) with self-administration of medications as an ADL-related function shall not take into consideration whether the Applicant requires sliding scale insulin and the Applicant's level of independence in self-administering sliding scale insulin.(II) Sliding scale insulin shall be considered along with other skilled and/or rehabilitative services for which TennCare could authorize level 2 NF reimbursement.(III) The maximum individual acuity score for self-administration of medication shall be two (2).(IV) The maximum individual acuity score for sliding scale insulin shall be one (1(v) Maximum Skilled Services Acuity Score: (I) The highest individual acuity score across all of the skilled and/or rehabilitative services shall be the Applicant's total acuity score for skilled and/or rehabilitative services.(II) The maximum possible acuity score for skilled and/or rehabilitative services shall be five (5).(d) Maximum Acuity Score 1. The maximum possible acuity score for Activities of Daily Living (ADL) or related deficiencies shall be twenty-one (21).2. The maximum possible acuity score for skilled and/or rehabilitative services shall be five (5).3. The maximum possible total NF LOC acuity score shall be twenty-six (26).(e) Calculating an Applicant's Total Acuity Score.1. Subject to the conditions set forth in 1200-13-01-.10(6)(c) 5., an Applicant's acuity score for each functional measure (i.e., eating, toileting, orientation, communication, self-administration of medication, or behavior), or in the case of transfer and mobility, the Applicant's acuity score across both measures shall be added in order to determine the Applicant's total ADL or related acuity score (up to a maximum of 21).2. The Applicant's total ADL or related acuity score shall then be added to the Applicant's skilled services acuity score (up to a maximum of 5) in order to determine the Applicant's total acuity score (up to a maximum of 26).(7) PreAdmission Evaluation Denials and Appeal Rights.(a) A TennCare Eligible or the legal representative of the TennCare Eligible has the right to appeal the denial of a PAE and to request an Administrative Hearing by submitting a written letter of appeal to the Bureau of TennCare, Division of Long-Term Services and Supports, within thirty (30) calendar days of receipt of the notice of denial.(b) If the Bureau denies a PAE, the Applicant will be notified in the following manner: 1. A written Notice of denial shall be sent to the Applicant and, where applicable, to the Designated Correspondent. A Notice of denial shall also be provided to the NF. This notice shall advise the Applicant of the right to appeal the denial decision within thirty (30) calendar days. The notice shall also advise the Applicant of the right to submit within thirty (30) calendar days either the original PAE with additional information for review or a new PAE. The Notice shall be mailed to the Applicant's address as it appears upon the PAE. If no address appears on the PAE and supporting documentation, the Notice will be mailed to the NF for forwarding to the Applicant.2. If the PAE is resubmitted with additional information for review or if a new PAE is submitted, and the Bureau continues to deny the PAE, another written notice of denial shall be sent as described in (7)(b)1.(c) The Applicant has the right to be represented at the hearing by anyone of his/her choice. The hearing will be conducted according to the provisions of the Tennessee Uniform Administrative Procedures Act.(d) Reasonable accommodations shall be made for Applicants with disabilities who require assistance with an appeal.(e) Any Notice required pursuant to this section shall be a plain language written Notice.(f) When a PAE is approved for a fixed period of time with an Expiration Date determined by the Bureau, the Applicant shall be provided with a Notice of appeal rights, including the opportunity to submit an appeal within thirty (30) calendar days of receipt of the notice of denial. Nothing in this section shall preclude the right of the Applicant to submit a new PAE establishing medical necessity of care when the Expiration Date has been reached.Tenn. Comp. R. & Regs. 1200-13-01-.10
Original rule filed October 22, 1981; effective December 7, 1981. Amendment filed March 1, 1982; effective April 15, 1982. Amendment filed June 23, 1983; effective July 25, 1983. Amendment filed May 24, 1985; effective June 23, 1985. Amendment filed November 9, 1988; effective December 24, 1988. Amendment filed March 30, 1995; effective June 15, 1995. Repeal and new rule filed June 29, 2000; effective September 12, 2000. Amendment filed July 24, 2003; effective October 7, 2003. Amendment filed September 30, 2005; effective December 14, 2005. Public necessity rule filed July 1, 2009; effective through December 13, 2009. Amendment filed September 11, 2009; effective December 10, 2009. Emergency rules filed March 1, 2010; effective through August 28, 2010. Amendments filed May 27, 2010; effective August 25, 2010. Emergency rule filed June 29, 2012; effective through December 26, 2012. Repeal and new rule filed September 26, 2012; effective December 25, 2012. Emergency rule filed June 30, 2015; effective through December 27, 2015. Amendment filed April 14, 2015; effective July 13, 2015. Amendment filed September 23, 2015; effective December 22, 2015. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 30, 2016; effective December 29, 2016. Amendments filed July 3, 2017; effective October 1, 2017. Emergency rules filed November 20, 2020; effective through May 19, 2021. Amendments filed February 17, 2021; effective May 18, 2021. Amendments filed November 1, 2022; effective 1/30/2023.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 and TennCare II/III Section 1115(a) Medicaid Demonstration Waiver Extension.