Bureau of TennCare

2009TennCare 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.

Topics:

• 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)

• 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)• 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

• 59.1% White

• 30.7% Black

• 4.6% Hispanic

• 5.6% Other

• Considerations– Cultural perspectives– Gender– Religious or moral preferences– Limited English Proficiency

Cultural Competency in TennCare

MCC Change ScheduleStarting 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

REPORTING FRAUD & ABUSE

Cash for Tips Policyhttp://www.tn.gov/tnoig/Documents/IncentiveProgram_OIG.pdf

Office of Inspector General

1-800-433-3982

FAX: 615-256-3852http://www.tn.gov/tnoig/

Tips can be anonymous

•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

ARREST BY COUNTIES

WEST 62

MIDDLE 647

EAST 223

FALCON III 32

FALCON IV 16

TOTAL 980

Office of Inspector General Statistics

Types of Arrests

Access To Ins 55

Drug Div/Sale 346

Drug Div/Forgery 331

Doctor Shopping 76

Inel Per Using 17

Asset Diversion 7

Income 45

Theft of Svcs 11

Out of State 13

ID - Theft 28

Aiding & Abetting 3

Falcon III 32

Falcon IV 16

   

Total Arrests 980

RESOURCES

Hotline 114

Website 12

Law-Email 10

Law-Ltr 18

Law-CID 360

Law-Hotline 130

Law-Fax 23

State Agency 62

*** PROVIDER *** 200

Mail 14

Wage Ltr 23

Internal Data Mining 14

   

   

Total Resources 980

Office of Inspector General Statistics

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

• 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

Why restructure the long-term care system?

Fragmentation

• 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

• 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

• 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

How will CHOICES change the current 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

• 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

• 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

How will CHOICES impact persons who need LTC?

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)

TENNESSEE AREA AGENCIES ON AGING & DISABILITY

Area Name Address City State Zip Phone Fax

1 First TN Dev. District 207 North Boone StreetSuite 800

Johnson City TN 37604 423-928-0224 423-928-5209

2 East TN Human Resource Agency 9111 Cross Park Drive,Suite D100

Knoxville TN 37923 865-691-2551ext. 216

865-531-7216

3 Southeast TN Dev. District 1000 Riverfront Parkway Chattanooga TN 37402 423-266-5781 423-424-4225

4 Upper Cumberland Dev. District 1225 South Willow Ave. Cookeville TN 38506 931-432-4111 931-432-6010

5 Greater Nashville Regional Council 501 Union Street, 6th Floor Nashville TN 37219 615-862-8828 615-862-8840

6 South Central TN Dev. District 815 South Main Street Columbia TN 38402 931-381-2040 931-381-2053

7 Northwest Dev. District 124 Weldon Drive Martin TN 38237 731-587-4213 731-588-5833

8 Southwest TN Dev. District 27 Conrad Drive, Suite 150 Jackson TN 38305 731-668-7112 731-668-6438

9 Aging Commission of the Mid-South 2670 Union Avenue Extended,Suite 1000

Memphis TN 38112 901-324-6333 901-327-7755

12

3

45

6

7

89

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

• 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 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

• 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 Direction– Allows consumers to select, direct, and employ their own

caregivers• Personal Care• Attendant Care• Homemaker• 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• 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

• 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)

• 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?

– 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?

• Nursing Facilities are NOT obligated to contract with each MCOBUT……………

• 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

• 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

• 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)

When will CHOICESbe implemented?

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

• Phased Implementation– Middle Region – March 1, 2010– East and West Regions to follow –

likely first of FY 2011 (July 1, 2010)

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:

Medical Necessity

1. It must be recommended by a health care provider

2. It must be required to diagnose or treat the medical condition

3. It must be safe and effective4. It must not be experimental or investigational5. It must be the least costly alternative course of

diagnosis or treatment that is adequate for the enrollee’s medical condition

Provider Inquiries

1. Contact “Provider Services” at the MCC2. Contact your assigned MCC Provider

Representative

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

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 Inquiries

5. Official Provider Complaint Process orIndependent Review Process through Tennessee Department of Commerce & Insurance at http://tn.gov/commerce/tenncare/PCIR.shtml

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

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

Tennessee Anytime Step-By-Step Online TennCare Eligibility Verification

1. Type in www.tn.gov/tenncare 2. Click “For Providers” at left of page 3. Click “Verify Eligibility” under Provider Links 4. Click “Online Eligibility Verification” in center of page 5. Click “OK” in message box that pops up telling you that you are being taken

to a different webpage: TennCare Online Services https://www.tennesseeanytime.org/tcmis/tennessee/Security/logon.asp

6. Type in User Name and Password in the Log In section at bottom left of page and click “Log In”

7. Click “Eligibility Verification” 8. Enter either the “Recipient ID” or “Recipient SSN and Recipient Date of

Birth”

How to subscribe for Online TennCare Eligibility Verification

1. Type in www.tn.gov/tenncare 2. Click “For Providers” at left of page 3. Click “Verify Eligibility” under Provider Links 4. Click “Online Eligibility Verification” in center of page 5. Click “OK” in message box that pops up telling you that you are being taken

to a different webpage: TennCare Online Services https://www.tennesseeanytime.org/tcmis/tennessee/Security/logon.asp

6. Click “Learn how to subscribe” in center of page 7. Under Sign Up in Three Easy Steps- click “Create a TN.gov account” 8. Under Subscription Services – check mark “TennCare Eligibility Information

Search” 9. Complete Business/Account Information – click “Continue” 10. Complete Technical Contact Information – click “Continue 11. Setup Username, Password and Security Questions – click “Continue” 12. Complete Billing Information – click “Continue” 13. Print the Service Agreement, Sign and Mail to address indicated within 7

business days or account will be disabled

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

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 (continued)

• Eligibility verification and claims are handled by TDMHDD

• For additional information:https://mhddapps.state.tn.us/Uninsured/(S(mpzslwnjmlcjzy45tsupjczm))/Default.aspx

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

E-Mail subscription:Sign up at:http://tn.gov/tenncare/pro-emailsubcrip.html

Provider Communications

RSS Feed:Sign up at:http://tn.gov/tenncare/providers.html

State/Government Email Address Domain Change

• The state email domain address has changed from:

@state.tn.us

to

@tn.gov

1-800-852-2683

TENNCARE PROVIDER SERVICES