Amendment

AMENDMENT NUMBER 4 CONTRACTOR RISK AGREEMENT BETWEEN THE STATE OF TENNESSEE, d.b.a. TENNCARE AND AMERIGROUP TENNESSEE, INC. CONTRACT NUMBER: FA- 07-16936-00

Exhibit 10.4
AMENDMENT NUMBER 4
CONTRACTOR RISK AGREEMENT
BETWEEN
THE STATE OF TENNESSEE,
d.b.a. TENNCARE
AND
AMERIGROUP TENNESSEE, INC.
CONTRACT NUMBER: FA- 07-16936-00
For and in consideration of the mutual promises herein contained and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree to clarify and/or amend the Contractor Risk Agreement (CRA) by and between the State of Tennessee TennCare Bureau, hereinafter referred to as TENNCARE, and AMERIGROUP TENNESSEE, INC., hereinafter referred to as the CONTRACTOR as specified below.
Titles and numbering of paragraphs used herein are for the purpose of facilitating use of reference only and shall not be construed to infer a contractual construction of language.
1.   The preamble shall be amended to add references to long-term care services and delete references to “State Onlys and Judicials” and shall read as follows:
This Agreement is entered into by and between THE STATE OF TENNESSEE, hereinafter referred to as “TENNCARE” or “State” and AMERIGROUP, Tennessee, Inc., hereinafter referred to as “the CONTRACTOR”.
     WHEREAS, the purpose of this Agreement is to assure the provision of quality physical health, behavioral health, and long-term care services while controlling the costs of such services;
     WHEREAS, consistent with waivers granted by the Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, the State of Tennessee has been granted the authority to pay a monthly prepaid capitated payment amount to Health Maintenance Organizations (HMOs), referred to as Managed Care Organizations or MCOs, for rendering or arranging necessary physical health, behavioral health, and long-term care services to persons who are enrolled in Tennessee’s TennCare program;
     WHEREAS, the Tennessee Department of Finance and Administration is the state agency responsible for administration of the TennCare program and is authorized to contract with MCOs for the purpose of providing the services specified herein for the benefit of persons who are eligible for and are enrolled in the TennCare program; and
     WHEREAS, the CONTRACTOR is a Managed Care Organization as described in the 42 CFR Part 438, is licensed to operate as an HMO in the State of Tennessee, has met additional qualifications established by the State, is capable of providing or arranging for the provision of covered services to persons who are enrolled in the TennCare

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program for whom it has received prepayment, is engaged in said business, and is willing to do so upon and subject to the terms and conditions hereof;
NOW, THEREFORE, in consideration of the mutual promises contained herein the parties have agreed and do hereby enter into this Agreement according to the provisions set forth herein:
2.   Section 1 shall be deleted in its entirety and replaced with the following:
SECTION 1 — DEFINITIONS, ACRONYMS, AND ABBREVIATIONS
The terms used in this Agreement shall be given the meaning used in TennCare rules and regulations. However, the following terms when used in this Agreement, shall be construed and/or interpreted as follows, unless the context expressly requires a different construction and/or interpretation. In the event of a conflict in language between these Definitions, Attachments, and other Sections of this Agreement, the specific language in Sections 2 through 4 of this Agreement shall govern.
Administrative Cost — All costs to the CONTRACTOR related to the administration of this Agreement that are non-medical in nature including, but not limited to:
  1.   Meeting general requirements in Section 2.2;
 
  2.   Enrollment and disenrollment in accordance with Section 2.4 and 2.5;
 
  3.   Additional services and use of incentives in Section 2.6.6;
 
  4.   Health education and outreach in Section 2.7.4;
 
  5.   Meeting requirements for coordination of services specified in Section 2.9, including care coordination for CHOICES members and the CONTRACTOR’s electronic visit verification system except as otherwise provided in Section 3;
 
  6.   Establishing and maintaining a provider network in accordance with the requirements specified in Section 2.11, Attachments III, IV and V;
 
  7.   Utilization Management as specified in Section 2.14;
 
  8.   Quality Management and Quality Improvement activities as specified in Section 2.15;
 
  9.   Production and distribution of Member Materials as specified in Section 2.17;
 
  10.   Customer service requirements in Section 2.18;
 
  11.   Complaint and appeals processing and resolution in accordance with Section 2.19;
 
  12.   Determination of recoveries from third party liability resources in accordance with Section 2.21.4;
 
  13.   Claims Processing in accordance with Section 2.22;

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  14.   Maintenance and operation of Information Systems in accordance with Section 2.23;
 
  15.   Personnel requirements in Section 2.29;
 
  16.   Production and submission of required reports as specified in Section 2.30;
 
  17.   Administration of this Agreement in accordance with policies and procedures;
 
  18.   All other Administration and Management responsibilities as specified in Attachments II through IX and Sections 2.20, 2.21, 2.24, 2.25, 2.26, 2.27, and 2.28;
 
  19.   Premium tax; and
 
  20.   Costs of subcontractors engaged solely to perform a non-medical administrative function for the CONTRACTOR specifically related to securing or fulfilling the CONTRACTOR’s obligations to TENNCARE under the terms of this Agreement (e.g., claims processing) are considered to be an “administrative cost”.
Adult Protective Services (APS) — An office within the Tennessee Department of Human Services that investigates reports of abuse, neglect (including self-neglect) or financial exploitation of vulnerable adults. APS staff assess the need for protective services and provide services to reduce the identified risk to the adult.
Adverse Action — Any action taken by the CONTRACTOR to deny, reduce, terminate, delay or suspend a covered service as well as any other acts or omissions of the CONTRACTOR which impair the quality, timeliness or availability of such benefits.
Affiliate — Any person, firm, corporation (including, without limitation, service corporation and professional corporation), partnership (including, without limitation, general partnership, limited partnership and limited liability partnership), limited liability company, joint venture, business trust, association or other entity or organization that now or in the future directly or indirectly controls, is controlled by, or is under common control with the CONTRACTOR.
Appeal Procedure — The process to resolve an enrollee’s right to contest verbally or in writing, any adverse action taken by the CONTRACTOR to deny, reduce, terminate, delay, or suspend a covered service as well as any other acts or omissions of the CONTRACTOR which impair the quality, timeliness or availability of such benefits. The appeal procedure shall be governed by TennCare rules and regulations and any and all applicable court orders and consent decrees.
Area Agency on Aging and Disability (AAAD) — The agency designated by the Tennessee Commission on Aging and Disability (TCAD) to develop and administer a comprehensive and coordinated community based system in, or serving, a defined planning and service area.
At-Risk — As it relates to the CHOICES program, SSI eligible adults age sixty-five (65) and older or age twenty-one (21) or older with physical disabilities, who do not meet the established level of care criteria for nursing facility services, but have a lesser number or level of functional deficits in activities of daily living as defined in TennCare rules and regulations, such that, in the absence of the provision of a moderate level of home and community based services, 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.

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Base Capitation Rate — The amount established by TENNCARE pursuant to the methodology described in Section 3 of this Agreement as compensation for the provision of all covered services except for behavioral services for Priority enrollees.
Behavioral Health Assessment — Procedures used to diagnose mental health or substance abuse conditions and determine treatment plans.
Behavioral Health Services — Mental health and/or substance abuse services.
Benefits — The package of health care services, including physical health, behavioral health, and long-term care services, that define the covered services available to TennCare enrollees enrolled in the CONTRACTOR’s MCO pursuant to this Agreement.
Bureau of TennCare — The division of the Tennessee Department of Finance and Administration (the single state Medicaid agency) that administers the TennCare program. For the purposes of this Agreement, Bureau of TennCare shall mean the State of Tennessee and its representatives.
Business Day — Monday through Friday, except for State of Tennessee holidays.
CAHPS (Consumer Assessment of Healthcare Providers and Systems) — A comprehensive and evolving family of surveys that ask consumers and patients to evaluate various aspects of health care.
Capitation Payment — The fee that is paid by TENNCARE to the CONTRACTOR for each member covered by this Agreement. The CONTRACTOR is at financial risk as specified in Section 3 of this Agreement for the payment of services incurred in excess of the amount of the capitation payment. “Capitation Payment” includes Base Capitation Rate payments and Priority Add-on rate payments, unless otherwise specified.
Capitation Rate — The amount established by TENNCARE pursuant to the methodology described in Section 3 of this Agreement, including the base capitation rates and priority add-on rate.
Care Coordinator — The individual who has primary responsibility for performance of care coordination activities for a CHOICES member as specified in this Agreement and meets the qualifications specified in Section 2.9.6.
Care Coordination Team — If an MCO elects to use a care coordination team, the care coordination team shall consist of a care coordinator and specific other persons with relevant expertise and experience who are assigned to support the care coordinator in the performance of care coordination activities for a CHOICES member as specified in this Agreement and in accordance with Section 2.9.6.
Care Coordination Unit — A specific group of staff within the MCO’s organization dedicated to CHOICES that is comprised of care coordinators and care coordinator supervisors and which may also include care coordination teams.
Caregiver — For purposes of CHOICES, a person who is (a) a family member or is unrelated to the member but has a close, personal relationship with the member and (b) routinely involved in

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providing unpaid support and assistance to the member. A caregiver may be also designated by the member as a representative for CHOICES or for consumer direction of HCBS.
CEA — Cost Effective Alternative (see Section 2.6.5 of this Agreement).
Centers of Excellence (COE) for AIDS — Integrated networks designated by the State as able to provide a standardized and coordinated delivery system encompassing a range of services needed by TennCare enrollees with HIV or AIDS.
Centers of Excellence (COE) for Behavioral Health COEs that provide a limited range of direct services to children in and at risk for state custody (i.e., not just DCS children/youth). These services are to augment the existing service system. Therefore, COEs for Behavioral Health typically only provide services where there is sufficient complexity in the case to warrant the COE for Behavioral Health resources and/or all other means to provide the service in the TennCare network have been exhausted.
CFR — Code of Federal Regulations.
Child Protective Services (CPS) A program division of the Tennessee Department of Children’s Services whose purpose is to investigate allegations of child abuse and neglect and provide and arrange preventive, supportive, and supplementary services.
CHOICES Group (Group) — One of the three groups of TennCare enrollees who are enrolled in CHOICES. There are three CHOICES groups:
  1.   Group 1
 
      Medicaid enrollees of all ages who are receiving Medicaid-reimbursed care in a nursing facility.
 
  2.   Group 2
 
      Persons age sixty-five (65) and older and adults age twenty-one (21) and older with physical disabilities who meet the nursing facility level of care, who qualify for TennCare either as SSI recipients or as members of the CHOICES 217-Like HCBS Group, and who need and are receiving HCBS as an alternative to nursing facility care. The CHOICES 217-Like HCBS Group includes persons who could have been eligible under 42 CFR 435.217 had the state continued its 1915(c) HCBS waiver for elders and/or persons with physical disabilities. TENNCARE has the discretion to apply an enrollment target to this group, as described in TennCare rules and regulations.
 
  3.   Group 3
 
      Persons age sixty-five (65) and older and adults age twenty-one (21) and older with physical disabilities who qualify for TennCare as SSI recipients, who do not meet the nursing facility level of care, but who, in the absence of HCBS, are “at-risk” for nursing facility care, as defined by the State. TENNCARE has the discretion to apply an enrollment target to this group, as described in TennCare rules and regulations. Group 3 will not be included in CHOICES on the date of CHOICES implementation. TENNCARE intends to include CHOICES Group 3 on January 1, 2011. TENNCARE will notify the CONTRACTOR at least sixty (60) days prior to the proposed date for including Group 3 in CHOICES. As of the date specified in that notice, the CONTRACTOR shall accept members in CHOICES Group 3 and shall implement all of the requirements in this Agreement that are applicable to CHOICES Group 3.

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CHOICES Implementation Date The date, as determined by TENNCARE, when the CONTRACTOR shall begin providing long-term care services to CHOICES members.
CHOICES Member — A member who has been enrolled by TENNCARE into CHOICES.
Clean Claim — A claim received by the CONTRACTOR for adjudication that requires no further information, adjustment, or alteration by the provider of the services in order to be processed and paid by the CONTRACTOR.
Clinical Practice Guidelines — Systematically developed tools or standardized specifications for care to assist practitioners and patient decisions about appropriate care for specific clinical circumstances. Such guidelines are typically developed through a formal process and are based on authoritative sources that include clinical literature and expert consensus.
Clinically Related Group 1: Severely and/or Persistently Mentally Ill (SPMI) — Persons in this group are 18 years or older with a valid DSM-IV-TR (and subsequent revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes. They are recently severely impaired and the duration of their severe impairment totals six months or longer of the past year.
Clinically Related Group 2: Persons with Severe Mental Illness (SMI) — Persons in this group are 18 years or older with a valid DSM-IV-TR (and subsequent revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes. Persons in this group are recently severely impaired and the duration of their severe impairment totals less than six months of the past year.
Clinically Related Group 3: Persons who are Formerly Severely Impaired — Persons in this group are 18 years or older with a valid DSM-IV-TR (and subsequent revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes. Persons in this group are not recently severely impaired but have been severely impaired in the past and need services to prevent relapse.
Clinically Related Group 4: Persons with Mild or Moderate Mental Disorders — Persons in this group are 18 years or older with a valid DSM-IV-TR (and subsequent revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes. Persons in this group are not recently severely impaired and are either not formerly severely impaired or are formerly severely impaired but do not need services to prevent relapse.
Clinically Related Group 5: Persons who are not in clinically related groups 1-4 as a result of their diagnosis — Persons in this group are 18 years or older diagnosed with DSM-IV-TR (and subsequent revisions) substance use disorders, developmental disorders or V-codes only.
CMS — Centers for Medicare & Medicaid Services.
Community-Based Residential Alternatives to Institutional Care (Community-Based Residential Alternatives) — Residential services that offer a cost-effective, community-based alternative to nursing facility care for persons who are elderly and/or adults with physical disabilities. This includes, but is not limited to, assisted care living facilities, adult care homes, and companion care.

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Complaint — A written or verbal expression of dissatisfaction from a member about an action taken by the CONTRACTOR or service provider other than an adverse action. The CONTRACTOR shall not treat anything as a complaint that falls within the definition of adverse action.
Contract Provider — A provider that is employed by or has signed a provider agreement with the CONTRACTOR to provide covered services.
Consumer — Except when used regarding consumer direction of HCBS, an individual who uses a mental health or substance abuse service.
Consumer-Directed Worker (Worker) — An individual who has been hired by a CHOICES member participating in consumer direction of HCBS or his/her representative to provide one or more eligible HCBS to the member. Worker does not include an employee of an agency that is being paid by an MCO to provide HCBS to the member.
Consumer Direction of HCBS — The opportunity for a CHOICES member assessed to need specified types of HCBS including attendant care, personal care, homemaker, in-home respite, companion care and/or any other service specified in TennCare rules and regulations as available for consumer direction to elect to direct and manage (or to have a representative direct and manage) certain aspects of the provision of such services—primarily, the hiring, firing, and day- to-day supervision of consumer-directed workers delivering the needed service(s).
Cost Neutrality Cap — The requirement that the cost of providing care to a member in CHOICES Group 2, including HCBS, home health, and private duty nursing, shall not exceed the cost of providing nursing facility services to the member, as determined in accordance with TennCare policy.
Covered Services — See Benefits.
CRA — Contractor Risk Agreement; also referred to as “Agreement.”
CRG (Clinically Related Group) — Defining and classifying consumers 18 years or older into clinically related groups involves diagnosis, the severity of functional impairment, the duration of severe functional impairment, and the need for services to prevent relapse. Based on these criteria, there are five clinically related groups:
  Group 1   —      Persons with Severe and Persistent Mental Illness (SPMI)
 
  Group 2   —      Persons with Severe Mental Illness (SMI)
 
  Group 3   —      Persons who were Formerly Severely Impaired and need services to prevent relapse
 
  Group 4   —      Persons with Mild or Moderate Mental Disorder
 
  Group 5   —      Persons who are not in Clinically Related Groups 1 — 4 as a result of their diagnosis being substance use disorder, developmental disorder, or V-codes
Days — Calendar days unless otherwise specified.

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Dental Benefits Manager (DBM) — An entity responsible for the provision and administration of dental services, as defined by TENNCARE.
DHHS — United States Department of Health and Human Services.
Disenrollment — The removal of an enrollee from participation in the CONTRACTOR’s MCO and deletion from the enrollment file furnished by TENNCARE to the CONTRACTOR.
Electronic Visit Verification (EVV) System — An electronic system into which provider staff and consumer-directed workers can check-in at the beginning and check-out at the end of each period of service delivery to monitor member receipt of HCBS and which may also be utilized for submission of claims.
Eligible — Any person certified by TENNCARE as eligible to receive services and benefits under the TennCare program. As it relates to CHOICES a person is eligible to receive CHOICES benefits only if he/she has been enrolled in CHOICES by TENNCARE.
Emergency Medical Condition — A physical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following (1) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part.
Emergency Services — Covered inpatient and outpatient services that are as follows: (1) furnished by a provider that is qualified to furnish these services; and (2) needed to evaluate or stabilize an emergency medical condition.
Enrollee — A person who has been determined eligible for TennCare and who has been enrolled in the TennCare program (see Member, also).
Enrollment — The process by which a TennCare enrollee becomes a member of the CONTRACTOR’s MCO.
EPSDT — The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid’s comprehensive and preventive child health program for individuals under the age of 21. EPSDT was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA ‘89) legislation and includes periodic screening, vision, dental, and hearing services. In addition, Section 1905(r)(5) of the Social Security Act (the Act) requires that any medically necessary health care service listed at Section 1905(a) of the Act be provided to an EPSDT recipient even if the service is not available under the State’s Medicaid plan to the rest of the Medicaid population. The federal regulations for EPSDT are in 42 CFR Part 441, Subpart B.
Essential Hospital Services — Tertiary care hospital services to which it is essential for the CONTRACTOR to provide access. Essential hospital services include, but are not limited to, neonatal, perinatal, pediatric, trauma and burn services.
Evidence-Based Practice — A clinical intervention that has demonstrated positive outcomes in several research studies to assist consumers in achieving their desired goals of health and wellness; specifically, the evidence-based practices recognized by the Substance Abuse and

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Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services (CMHS).
Expenditure Cap — The annual limit on expenditures for HCBS, excluding home modifications, for CHOICES members in CHOICES Group 3. The expenditure cap is $15,000.
Facility — Any premises (a) owned, leased, used or operated directly or indirectly by or for the CONTRACTOR or its affiliates for purposes related to this Agreement; or (b) maintained by a subcontractor or provider to provide services on behalf of the CONTRACTOR.
Fee-for-Service — A method of making payment for health services based on a fee schedule that specifies payment for defined services.
Fiscal Employer Agent (FEA) — An entity contracting with the State and/or an MCO that helps CHOICES members participating in consumer direction of HCBS. The FEA provides both financial administrative services and supports brokerage to CHOICES members participating in consumer direction of HCBS.
FQHC — Federally Qualified Health Center.
Grand Region — A defined geographical region that includes specified counties in which the CONTRACTOR is authorized to enroll and serve TennCare enrollees in exchange for a monthly capitation payment. The CONTRACTOR shall serve an entire Grand Region. The following counties constitute the Grand Regions in Tennessee:
East Grand Region –    Anderson, Bledsoe, Blount, Bradley, Campbell, Carter, Claiborne, Cocke, Franklin, Grainger, Greene, Grundy, Hamblen, Hamilton, Hancock, Hawkins, Jefferson, Johnson, Knox, Loudon, Marion, McMinn, Meigs, Monroe, Morgan, Polk, Rhea, Roane, Scott, Sequatchie, Sevier, Sullivan, Unicoi, Union, and Washington Counties
 
Middle Grand Region –    Bedford, Cannon, Cheatham, Clay, Coffee, Cumberland, Davidson, DeKalb, Dickson, Fentress, Giles, Hickman, Houston, Humphreys, Jackson, Lawrence , Lewis, Lincoln, Macon, Marshall, Maury, Montgomery, Moore, Overton, Perry, Pickett, Putnam, Robertson, Rutherford, Smith, Stewart, Sumner, Trousdale, Van Buren, Warren, Wayne, White, Williamson, and Wilson Counties
 
West Grand Region –    Benton, Carroll, Chester, Crockett, Decatur, Dyer, Fayette, Gibson, Hardeman, Hardin, Haywood, Henderson, Henry, Lake, Lauderdale, Madison, McNairy, Obion, Shelby, Tipton, and Weakley Counties
Grand Rounds — As used with respect to CHOICES members residing in a nursing facility, a planned quarterly meeting between nursing facility staff and MCO staff, including, at minimum, the care coordinator(s) assigned to residents of the facility conducted in order to: (1) address issues or concerns regarding members who have experienced a potential significant change in needs or circumstances or about whom the nursing facility or MCO has concerns (not necessarily all members who are residents of the facility); (2) identify any change in services or interventions for the members, including but not limited to changes in the members’ plans of care or supplements to the members’ plans of care; and (3) facilitate access to and coordination of physical health and/or behavioral health services needed by the members and to ensure the proper

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management of the members’ acute and/or chronic conditions. At least two of the quarterly Grand Rounds per year shall be conducted on-site in the facility.
Healthcare Effectiveness Data and Information Set (HEDIS) — The most widely used set of standardized performance measures used in the managed care industry, designed to allow reliable comparison of the performance of managed health care plans. HEDIS is sponsored, supported, and maintained by the National Committee for Quality Assurance.
Health Maintenance Organization (HMO) — An entity certified by TDCI under applicable provisions of TCA Title 56, Chapter 32.
HIPAA — Health Insurance Portability and Accountability Act.
Home and Community-Based Services (HCBS) — Services not covered by Tennessee’s Title XIX state plan that are provided as an alternative to long-term care institutional services in a nursing facility or an Intermediate Care Facility for the Mentally Retarded (ICF/MR). HCBS does not include home health or private duty nursing services.
Hospice — Services as described in TennCare rules and regulations and 42 CFR Part 418, which are provided to terminally ill individuals who elect to receive hospice services provided by a certified hospice agency.
Information System(s) (Systems) — A combination of computing and telecommunications hardware and software that is used in: (a) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of information, i.e., structured data (which may include digitized audio and video) and documents as well as non-digitized audio and video; and/or (b) the processing of information and non-digitized audio and video for the purposes of enabling and/or facilitating a business process or related transaction.
Immediate Eligibility — A mechanism by which the State can, based on a preliminary determination of a person’s eligibility for the CHOICES 217-Like HCBS Group, enroll the person into CHOICES Group 2 and provide immediate access to a limited package of HCBS pending a final determination of eligibility. To qualify for immediate eligibility, a person must be applying to receive covered HCBS, be determined by TENNCARE to meet nursing facility level of care, have submitted an application for financial eligibility determination to DHS, and be expected to qualify for CHOICES Group 2 based on review of the financial information provided by the applicant. Immediate eligibility shall only be for specified HCBS (no other covered services) and for a maximum of forty-five (45) days.
Intervention — An action or ministration that is intended to produce an effect or that is intended to alter the course of a pathologic process.
Law — Statutes, codes, rules, regulations, and/or court rulings.
Legally Appointed Representative — Any person appointed by a court of competent jurisdiction or authorized by legal process (e.g., power of attorney for health care treatment, declaration for mental health treatment) to determine the legal and/or health care interests of an individual and/or his/her estate.
Long-Term Care — The services of a nursing facility (NF), an Intermediate Care Facility for the Mentally Retarded (ICF/MR), or Home and Community-Based Services (HCBS).

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Long-Term Care Ombudsman Program — A statewide program for the benefit of individuals residing in long-term care facilities, which may include nursing homes, residential homes for the aged, assisted care living facilities, and community-based residential alternatives developed by the State. The Ombudsman is available to help these individuals and their families resolve questions or problems. The program is authorized by the federal Older Americans Act and administered by the Tennessee Commission on Aging and Disability (TCAD).
Managed Care Organization (MCO) An HMO that participates in the TennCare program.
Mandatory Outpatient Treatment (MOT) Process whereby a person who was hospitalized for psychiatric reasons and who requires outpatient treatment can be required by a court to participate in that behavioral health outpatient treatment to prevent deterioration in his/her mental condition.
Marketing — Any communication, from the CONTRACTOR to a TennCare enrollee who is not enrolled in the CONTRACTOR’s MCO, that can reasonably be interpreted as intended to influence the person to enroll in the CONTRACTOR’s MCO, or either to not enroll in, or to disenroll from, another MCO’s TennCare product.
Medical Expenses — Shall be determined as follows:
  1.   Medical Expenses include the amount paid to providers for the provision of covered physical health, behavioral health, and/or long-term care services to members pursuant to the following listed Sections of the Agreement:
  a.   Section 2.6.1, CONTRACTOR Covered Benefits;
 
  b.   Section 2.6.4, Second Opinions;
 
  c.   Section 2.6.5, Use of Cost Effective Alternative Services;
 
  d.   Section 2.7, Specialized Services except TENNderCare member and provider outreach and education, health education and outreach and advance directives;
 
  e.   Capitated payment to licensed providers;
 
  f.   Medical services directed by TENNCARE or an Administrative Law Judge; and
 
  g.   Net impact of reinsurance coverage purchased by the CONTRACTOR.
  2.   Medical Expenses do not include:
  a.   2.6.2 TennCare Benefits Provided by TENNCARE;
 
  b.   2.6.7 Cost sharing for services;
 
  c.   2.10 Services Not Covered;
 
  d.   Services eligible for reimbursement by Medicare; or

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  e.   The activities described in or required to be conducted in Attachments II through X, which are administrative costs.
  3.   Medical expenses shall be net of any TPL recoveries or subrogation activities.
 
  4.   This definition does not apply to NAIC filings.
Medical Loss Ratio (MLR) — The percentage of capitation payment received from TENNCARE that is used to pay medical expenses.
Medical Records — All medical, behavioral health, and long-term care histories; records, reports and summaries; diagnoses; prognoses; records of treatment and medication ordered and given; X- ray and radiology interpretations; physical therapy charts and notes; lab reports; other individualized medical, behavioral health, and long-term care documentation in written or electronic format; and analyses of such information.
Member — A TennCare enrollee who enrolls in the CONTRACTOR’s MCO under the provisions of this Agreement (see Enrollee, also).
Member Month — A month of coverage for a TennCare enrollee enrolled in the CONTRACTOR’s MCO.
Mental Health Services — The diagnosis, evaluation, treatment, residential care, rehabilitation, counseling or supervision of persons who have a mental illness.
NAIC — National Association of Insurance Commissioners.
National Committee for Quality Assurance (NCQA) — A nonprofit organization committed to assessing, reporting on and improving the quality of care provided by organized delivery systems.
Non-Contract Provider — Any provider that is not directly or indirectly employed by or does not have a provider agreement with the CONTRACTOR or any of its subcontractors pursuant to the Agreement between the CONTRACTOR and TENNCARE.
Office of the Comptroller of the Treasury — The Comptroller of the Treasury is a State of Tennessee constitutional officer elected by the General Assembly for a term of two years. Statutes prescribe the comptroller’s duties, the most important of which relate to audit of state and local government entities and participation in the general financial and administrative management of state government.
Office of Inspector General (OIG) — The State of Tennessee agency that investigates and may prosecute civil and criminal fraud and abuse of the TennCare program or any other violations of state law related to the operation of the TennCare program administratively, civilly or criminally.
One-Time HCBS — In-home respite, in-patient respite, assistive technology, minor home modifications, and/or pest control.
Ongoing HCBS — Community-based residential alternatives, personal care, attendant care, homemaker services, home-delivered meals, and/or adult day care.
PASRR — Preadmission Screening and Resident Review.

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Patient Liability — The amount of an enrollee’s income, as determined by DHS, to be collected each month to help pay for the enrollee’s long-term care services.
Pharmacy Benefits Manager (PBM) — An entity responsible for the provision and administration of pharmacy services.
Post-stabilization Care Services — Covered services, related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 CFR 438.114(e), to improve or resolve the member’s condition.
Prepaid Limited Health Service Organization (PLHSO) — An entity certified by TDCI under applicable provisions of TCA Title 56, Chapter 51.
Presumptive Eligibility — An established period of time (45 days) during which certain pregnant women are eligible for TennCare Medicaid. During this period of time the presumptively eligible enrollee must complete an application for Medicaid in order to stay on the program.
Primary Care Physician — A physician responsible for providing preventive and primary health care to patients; for initiating referrals for specialist care; and for maintaining the continuity of patient care. A primary care physician is generally a physician who has limited his/her practice of medicine to general practice or who is an Internist, Pediatrician, Obstetrician/Gynecologist, Geriatrician, or Family Practitioner. However, as provided in Section 2.11.2.4 of this Agreement, in certain circumstances other physicians may be primary care physicians if they are willing and able to carry out all PCP responsibilities in accordance with this Agreement.
Primary Care Provider (PCP) — A primary care physician or other licensed health practitioner practicing in accordance with state law who is responsible for providing preventive and primary health care to patients; for initiating referrals for specialist care; and for maintaining the continuity of patient care. A PCP may practice in various settings such as local health departments, FQHCs or community mental health agencies (CMHAs) provided that the PCP is willing and able to carry out all PCP responsibilities in accordance with this Agreement.
Prior Authorization — The act of authorizing specific services or activities before they are rendered or occur.
Priority Add-on Rate — The amount established by TENNCARE pursuant to the methodology described in Section 3 of this Agreement as compensation for the provision of behavioral health services for Priority enrollees.
Priority Enrollee — A TennCare enrollee who has been assessed within the past twelve (12) months as belonging in Clinically Related Groups (CRGs) 1, 2, or 3 if he/she is 18 years old or older, or Target Population Group (TPG) 2 if he/she is under the age of 18 years. This assessment as a Priority enrollee expires twelve (12) months after the assessment as been completed. In order for an individual to remain a Priority enrollee after the twelve (12) month period ends, he/she must be reassessed as continuing to meet the criteria to belong in CRGs 1, 2, or 3 or TPG 2 categories. The reassessment, like the initial assessment, expires after twelve (12) months unless another assessment is done. Also referred to as Priority member once the enrollee is enrolled in the CONTRACTOR’s MCO.

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Privacy Rule — Standards for the Privacy of Individually Identifiable Health Information at 45 CFR Part 160 and Part 164.
Protected Health Information (PHI) — Identifiable health information as defined in 45 CFR Part 160 and Part 164.
Provider — An institution, facility, agency, physician, health care practitioner, or other entity that is licensed or otherwise authorized to provide any of the covered services in the state in which they are furnished. Provider does not include consumer-directed workers (see Consumer-Directed Worker); nor does provider include the FEA (see Fiscal Employer Agent).
Provider Agreement — An agreement, using the provider agreement template approved by TDCI, between the CONTRACTOR and a provider or between the CONTRACTOR’s subcontractor and a provider that describes the conditions under which the provider agrees to furnish covered services to the CONTRACTOR’s members.
Quality Management/Quality Improvement (QM/QI) — The development and implementation of strategies to assess and improve the performance of a program or organization on a continuous basis. This includes the identification of key measures of performance, discovery and data collection processes, identification and remediation of issues, and systems improvement activities.
Recovery — A consumer driven process in which consumers are able to work, learn and participate fully in their communities. Recovery is the ability to live a fulfilling and productive life despite a disability.
Representative — In general, for CHOICES members, a person who is at least eighteen (18) years of age and is authorized by the member to participate in care planning and implementation and to speak and make decisions on the member’s behalf, including but not limited to identification of needs, preference regarding services and service delivery settings, and communication and resolution of complaints and concerns. As it relates to consumer direction of HCBS, a person who meets the qualifications specified in Section 2.9.7 of this Agreement, is authorized by the member to direct and manage the consumer’s worker(s), and signs a representative agreement.
Representative Agreement — The agreement between a CHOICES member electing consumer direction of HCBS who has a representative direct and manage the consumer’s worker(s) and the member’s representative that specifies the roles and responsibilities of the member and the member’s representative.
Resilience — A dynamic developmental process for children and adolescents that encompasses positive adaptation and is manifested by traits of self-efficacy, high self-esteem, maintenance of hope and optimism within the context of significant adversity.
Risk Agreement — An agreement signed by a member who will receive HCBS (or his/her representative) that includes, at a minimum, identified risks to the member of residing in the community and receiving HCBS, the consequences of such risks, strategies to mitigate the identified risks, and the member’s decision regarding his/her acceptance of risk. See Section 2.9.6 of this Agreement for related requirements.
Routine Care — Non-urgent and non-emergency medical or behavioral health care such as screenings, immunizations, or health assessments.

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Security Incident — The attempted or successful unauthorized access, use, disclosure, modification or destruction of information or interference with the system operations in an information system.
Security Rule — The Final Rule adopting Security Standards for the Protection of Electronic Health Information at 45 CFR Parts 160 and 164.
Seriously Emotionally Disturbed (SED) — Seriously Emotionally Disturbed shall mean persons who have been identified by the Tennessee Department of Mental Health and Developmental Disabilities or its designee as meeting the criteria provided below:
  1.   Person under the age of 18; and
 
  2.   Currently, or at any time during the past year, has had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-IV-TR (and subsequent revisions) of the American Psychiatric Association with the exception of DSM-IV-TR (and subsequent revisions) V- codes, substance use, and developmental disorders, unless these disorders co-occur with another diagnosable mental, behavioral, or emotional disturbance other than above exclusions. All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity and disabling effects; and
 
  3.   The diagnosable mental, behavioral, or emotional disorder identified above has resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, and community activities. Functional impairment is defined as difficulties that substantially interfere with or limit a child or adolescent in achieving or maintaining developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills and is evidenced by a Global Assessment of Functioning (GAF) score of 50 or less in accordance with the DSM-IV-TR (and subsequent revisions). Children and adolescents who would have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are included in this definition.
Service Agreement — The agreement between a CHOICES member electing consumer direction of HCBS (or the member’s representative) and the member’s consumer-directed worker that specifies the roles and responsibilities of the member (or the member’s representative) and the member’s worker.
Service Gap A delay in initiating any long-term care service and/or a disruption of a scheduled, ongoing HCBS that was not initiated by a member, including a late visit that was not remedied within the timeframe specified by TENNCARE.
Severely and/or Persistently Mentally Ill (SPMI) — Severely and/or Persistently Mentally Ill shall mean individuals who have been identified by the Tennessee Department of Mental Health and Developmental Disabilities or its designee as meeting the following criteria. These persons will be identified as belonging in one of the Clinically Related Groups that follow the criteria:
  1.   Age 18 and over; and

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  2.   Currently, or at any time during the past year, has had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet the diagnostic criteria specified within DSM-IV-TR (and subsequent revisions) of the American Psychiatric Association, with the exception of DSM-IV-TR (and subsequent revisions) V-codes, substance use disorders, and developmental disorders, unless these disorders co-occur with another diagnosable serious mental illness other than above exclusions. All of these disorders have episodic, recurrent, or persistent features, however, they vary in terms of severity and disabling effects; and
 
  3.   The diagnosable mental, behavioral, or emotional disorder identified above has resulted in functional impairment which substantially interferes with or limits major life activities. Functional impairment is defined as difficulties that substantially interfere with or limit role functioning in major life activities including basic living skills (e.g., eating, bathing, dressing); instrumental living skills (maintaining a household, managing money, getting around in the community, taking prescribed medication); and functioning in social, family, and vocational/educational contexts. This definition includes adults who would have met functional impairment criteria during the referenced year without the benefit of treatment or other support services.
Shall — Indicates a mandatory requirement or a condition to be met.
Span of Control — Information systems and telecommunications capabilities that the CONTRACTOR itself operates or for which it is otherwise legally responsible according to this Agreement. The CONTRACTOR’s span of control also includes Systems and telecommunications capabilities outsourced by the CONTRACTOR.
Specialty Services — Includes Essential Hospital Services and specialty physician services.
SSA — Social Security Administration.
SSI — Supplemental Security Income.
Start Date of Operations — The date, as determined by TENNCARE, when the CONTRACTOR shall begin providing services to members.
State — The State of Tennessee, including, but not limited to, any entity or agency of the state, such as the Tennessee Department of Finance and Administration, the Office of Inspector General, the Bureau of TennCare, the Tennessee Bureau of Investigation, Medicaid Fraud Control Unit, the Tennessee Department of Mental Health and Developmental Disabilities, the Tennessee Department of Children’s Services, the Tennessee Department of Health, the Tennessee Department of Commerce and Insurance, and the Office of the Attorney General.

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Subcontract — An agreement entered into by the CONTRACTOR with any other organization or person who agrees to perform any administrative function or service for the CONTRACTOR specifically related to securing or fulfilling the CONTRACTOR’s obligations to TENNCARE under the terms of this Agreement (e.g., claims processing, disease management) when the intent of such an agreement is to delegate the responsibility for any major service or group of services required by this Agreement. This shall also include any and all agreements between any and all subcontractors for the purposes related to securing or fulfilling the CONTRACTOR’s obligations to TENNCARE under the terms of this Agreement. Agreements to provide covered services as described in Section 2.6 of this Agreement shall be considered provider agreements and governed by Section 2.12 of this Agreement.
Subcontractor — Any organization or person who provides any function or service for the CONTRACTOR specifically related to securing or fulfilling the CONTRACTOR’s obligations to TENNCARE under the terms of this Agreement. Subcontractor does not include provider unless the provider is responsible for services other than those that could be covered in a provider agreement.
Substance Abuse Services — The assessment, diagnosis, treatment, detoxification, residential care, rehabilitation, education, training, counseling, referral or supervision of individuals who are abusing or have abused substances.
System Unavailability — As measured within the CONTRACTOR’s information systems span of control, when a system user does not get the complete, correct full-screen response to an input command within three (3) minutes after depressing the “Enter” or other function key.
Target Population Group (TPG) — An assessment mechanism for children and adolescents under the age of 18 to determine an individual’s level of functioning and severity of impairment due to a mental illness. Based on these criteria, there are three target population groups.
  1.   Target Population Group 2: Seriously Emotionally Disturbed (SED)
 
      Children and adolescents under 18 years of age with a valid DSM-IV-TR (and subsequent revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes. These children are currently severely impaired as evidenced by 50 or less Global Assessment of Functioning (GAF).
 
  2.   Target Population Group 3: At Risk of a (SED)
 
      Children and adolescents under 18 years of age without a valid DSM-IV-TR (and subsequent revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes. These children may or may not be currently seriously impaired as evidenced by Global Assessment of Functioning (GAF). These children have psychosocial issues that can potentially place them at risk of a SED.

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  3.   Target Population Group 4: Persons who do not meet criteria TPG Group 2 or 3
 
      Children and adolescents under 18 years of age without a valid DSM-IV-TR (and subsequent revisions) diagnosis and are not currently seriously impaired as evidenced by Global Assessment of Functioning (GAF). These children have no psychosocial issues that can potentially place them at risk of a SED.
TCA — Tennessee Code Annotated.
TENNCARE — TENNCARE shall have the same meaning as “State.”
TennCare or TennCare Program The program administered by the single state agency, as designated by the state and CMS, pursuant to Title XIX of the Social Security Act and the Section 1115 research and demonstration waiver granted to the State of Tennessee and any successor programs.
TennCare CHOICES in Long-Term Care (CHOICES) — A program in which long-term care services for elders and/or persons with physical disabilities are integrated into TennCare’s managed care delivery system.
TennCare Medicaid Enrollee — An enrollee who qualifies and has been determined eligible for benefits in the TennCare program through Medicaid eligibility criteria as described in TennCare rules and regulations.
TennCare Select — TennCare Select is a statewide MCO whose risk is backed by the State of Tennessee. TennCare Select was created to serve as a backup if other MCOs failed or there was inadequate MCO capacity and to be the MCO for certain populations, including children in state custody and children eligible for SSI. Children eligible for SSI may opt out of TennCare Select and enroll in another MCO.
TennCare Standard Enrollee — An enrollee who qualifies and has been determined eligible for benefits in the TennCare program through eligibility criteria designated as “TennCare Standard” as described in the approved TennCare waiver and the TennCare rules and regulations.
TENNderCare — Tennessee’s EPSDT program; see EPSDT.
Tennessee Bureau of Investigation, Medicaid Fraud Control Unit (TBI MFCU) — The Tennessee Bureau of Investigation’s Medicaid Fraud Control Unit has the authority to investigate and prosecute (or refer for prosecution) violations of all applicable state and federal laws pertaining to fraud in the administration of the Medicaid program, the provision of medical assistance, the activities of providers of medical assistance in the state Medicaid program (TennCare), allegations of abuse or neglect of patients in health care facilities receiving payments under the state Medicaid program, misappropriation of patients’ private funds in such facilities, and allegations of fraud and abuse in board and care facilities.
Tennessee Department of Children’s Services (DCS) — The state agency responsible for child protective services, foster care, adoption, programs for delinquent youth, probation, aftercare, treatment and rehabilitation programs for identified youth, and licensing for all child-welfare agencies, except for child (day) care agencies and child support.

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Tennessee Department of Commerce and Insurance (TDCI) — The state agency having the statutory authority to regulate, among other entities, insurance companies and health maintenance organizations.
Tennessee Department of Finance and Administration (F&A) — The state agency that oversees all state spending and acts as the chief corporate office of the state. It is the single state Medicaid agency. The Bureau of TennCare is a division of the Tennessee Department of Finance and Administration.
Tennessee Department of Health (DOH) — The state agency having the statutory authority to provide for health care needs in Tennessee.
Tennessee Department of Human Services (DHS) — The state agency having the statutory authority to provide human services to meet the needs of Tennesseans and enable them to achieve self-sufficiency. DHS is responsible for TennCare eligibility determinations (other than presumptive eligibility and S SI).
Tennessee Department of Mental Health and Developmental Disabilities (TDMHDD) — The state agency having the authority to provide care for persons with mental illness, substance abuse, and/or developmental disabilities. For the purposes of this Agreement, TDMHDD shall mean the State of Tennessee and its representatives.
Third Party Liability (TPL) — Any amount due for all or part of the cost of medical, behavioral health, or long-term care services from a third party.
Third Party Resource — Any entity or funding source other than the enrollee or his/her responsible party, which is or may be liable to pay for all or part of the cost of health care of the enrollee.
Transition Allowance — A per member allotment not to exceed two thousand dollars ($2,000) per lifetime which may, at the sole discretion of the CONTRACTOR, be provided as a cost-effective alternative to continued institutional care for a CHOICES member in order to facilitate transition from a nursing facility to the community when such member will, upon transition, receive more cost-effective non-residential home and community based services or companion care. Items that may be purchased or reimbursed are only those items that the member has no other means to obtain and that are essential in order to establish a community residence when such residence is not already established and to facilitate the member’s safe and timely transition, including rent and/or utility deposits, essential kitchen appliances, basic furniture, and essential basic household items, such as towels, linens, and dishes.
USC — United States Code.
Vital MCO Documents — Consent forms and notices pertaining to the reduction, denial, delay, suspension or termination of services. All vital documents shall be available in Spanish.
Warm Transfer — A telecommunications mechanism in which the person answering the call facilitates transfer to a third party, announces the caller and issue, and remains engaged as necessary to provide assistance.
Worker — See Consumer-Directed Worker.

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3.   Section 2.1.2 shall be amended by adding a new Section 2.1.2.4 and renumbering existing subparts accordingly, including any references thereto.
  2.1.2.4   Prior to the date of implementation of CHOICES in the Grand Region covered by this Agreement, as determined by TENNCARE, the CONTRACTOR shall demonstrate to TENNCARE’s satisfaction that it is able to meet all requirements related to the CHOICES program. The CONTRACTOR shall cooperate in this “readiness review,” which may include, but is not limited to, desk and on-site review of documents provided by the CONTRACTOR, a walk-through of the CONTRACTOR’s operations, system demonstrations (including systems connectivity testing), and interviews with CONTRACTOR’s staff. The scope of the review may include any and all requirements of the Agreement related to the CHOICES program, as determined by TENNCARE. Based on the results of the review activities, TENNCARE will issue a letter of findings and, if needed, will request a corrective action plan from the CONTRACTOR. TENNCARE will not enroll members into the CONTRACTOR’s CHOICES program until TENNCARE has determined that the CONTRACTOR is able to meet all requirements related to the CHOICES program.
4. Sections 2.3 shall be deleted in its entirety and replaced with the following:
2.3 ELIGIBILITY FOR TENNCARE
2.3.1 Overview
      TennCare is Tennessee’s Medicaid program operating under the authority of a research and demonstration project approved by the federal government pursuant to Section 1115 of the Social Security Act. Eligibility for TennCare is determined by the State in accordance with federal requirements and state law and policy.
2.3.2 Eligibility Categories
      TennCare currently consists of traditional Medicaid coverage groups (TennCare Medicaid) and an expanded population (TennCare Standard).
    2.3.2.1   TennCare Medicaid
 
        As provided in state rules and regulations, TennCare Medicaid covers all Medicaid mandatory eligibility groups as well as various optional categorically needy and medically needy groups, including children, pregnant women, the aged, and individuals with disabilities. Additional detail about eligibility criteria for covered groups is provided in state rules and regulations.
 
    2.3.2.2   TennCare Standard
 
        TennCare Standard includes the Standard Spend Down (SSD) population, the CHOICES 217-Like HCBS Group, and an expanded population of children. Additional detail about eligibility criteria for covered groups is provided in state rules and regulations.

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2.3.3 TennCare CHOICES Groups
      As specified in Section 2.6.1.5, in order to receive covered long-term care services, a member must be enrolled by TENNCARE into one of the CHOICES Groups (as defined in Section 1).
2.3.4 TennCare Applications
      The CONTRACTOR shall not cause applications for TennCare to be submitted. However, as provided in Section 2.9.6.3, the CONTRACTOR shall facilitate members’ eligibility determination for CHOICES enrollment.
2.3.5 Eligibility Determination and Determination of Cost Sharing
      The State shall have sole responsibility for determining the eligibility of an individual for TennCare. The State shall have sole responsibility for determining the applicability of TennCare cost sharing amounts, the collection of applicable premiums, and determination of patient liability.
2.3.6 Eligibility for Enrollment in an MCO
      Except for TennCare enrollees enrolled in the Program of All-Inclusive Care for the Elderly (PACE) and enrollees who are only receiving assistance with Medicare cost sharing, all TennCare enrollees will be enrolled in an MCO, including TennCare Select (see definition in Section 1 of this Agreement).
5. Section 2.4 shall be deleted in its entirety and replaced with the following:
2.4 ENROLLMENT IN AN MCO
2.4.1 General
      TENNCARE is solely responsible for enrollment of TennCare enrollees in an MCO.
2.4.2 Authorized Service Area
  2.4.2.1   Grand Region
 
      Enrollees will be enrolled in MCOs by Grand Region(s) of the state. The specific counties in each Grand Region are listed in Section 1 of this Agreement.
 
  2.4.2.2   CONTRACTOR’s Authorized Service Area
 
      The CONTRACTOR is authorized under this Agreement to serve enrollees who reside in the Grand Region(s) specified below:
 
      o East Grand Region      þ Middle Grand Region      o West Grand Region
2.4.3 Maximum Enrollment
  2.4.3.1   The CONTRACTOR agrees to accept enrollment in the CONTRACTOR’s MCO of up to seventy percent (70%) of the eligible population in the applicable Grand

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      Region. TENNCARE shall determine and notify the CONTRACTOR of the number of eligibles in the applicable Grand Region and the CONTRACTOR’s maximum enrollment limit, which shall be approximately seventy percent (70%) of the eligible population in the applicable Grand Region.
 
  2.4.3.2   TENNCARE shall establish an enrollment threshold for the CONTRACTOR that will equal approximately ninety percent (90%) of the maximum enrollment limit established in Section 2.4.3.1 above. This enrollment threshold may be adjusted by TENNCARE at its discretion.
 
  2.4.3.3   Once the CONTRACTOR’s enrollment threshold is met, TENNCARE may discontinue default assignment of enrollees to the CONTRACTOR’s MCO. Enrollees who select the CONTRACTOR or whose family members are enrolled in the CONTRACTOR’s MCO shall continue to be enrolled in the CONTRACTOR’s MCO until the maximum enrollment limit established in Section 2.4.3.1 above is met.
 
  2.4.3.4   Both TENNCARE and the CONTRACTOR recognize that management of the CONTRACTOR’s maximum enrollment limit and enrollment threshold within exact limits may not be possible. In the event enrollment in the CONTRACTOR’s MCO exceeds the maximum enrollment limit, TENNCARE may reduce enrollment in the CONTRACTOR’s MCO based on a plan established by TENNCARE that provides appropriate notice to the CONTRACTOR, allows appropriate choice of MCOs for enrollees, and meets the objectives of the TennCare program.
 
  2.4.3.5   The establishment of a maximum enrollment limit and/or of an enrollment threshold does not obligate the State to enroll a certain number of TennCare enrollees in the CONTRACTOR’s MCO and does not create in the CONTRACTOR any rights, interests or claims of entitlement to enrollment. The CONTRACTOR’s actual enrollment level will be determined through the MCO selection and assignment process described in Section 2.4.4 below.
 
  2.4.3.6   Upon the request of TENNCARE, the CONTRACTOR shall demonstrate to the satisfaction of TENNCARE it has the capacity to serve the number of enrollees in the maximum enrollment limit.
2.4.4 MCO Selection and Assignment
  2.4.4.1   General
 
      TENNCARE shall enroll individuals determined eligible for TennCare and eligible for enrollment in an MCO that is available in the Grand Region in which the enrollee resides. Enrollment in an MCO may be the result of an enrollee’s selection of a particular MCO or assignment by TENNCARE. Enrollment in the CONTRACTOR’s MCO is subject to the CONTRACTOR’s maximum enrollment limit and threshold (see Section 2.4.3) and capacity to accept additional members.

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  2.4.4.2   Current TennCare Enrollees
 
      TennCare enrollees who are known to be eligible for enrollment with the CONTRACTOR as of the start date of operations (defined in Section 1 of this Agreement) and residing in the Grand Region served by the CONTRACTOR shall be assigned by TENNCARE to the MCOs serving the Grand Region in accordance with the process described in Section 2.4.4.6 below. Except as otherwise provided in Section 2.4.4, this includes enrollees currently enrolled in another MCO, including TennCare Select.
 
  2.4.4.3   New TennCare Enrollees
 
  2.4.4.3.1   Except as otherwise provided in this Agreement, all non-SSI applicants shall be required at the time of their application to select an MCO other than TennCare Select from those MCOs available in the Grand Region where the applicant resides. If the applicant does not select an MCO, the person will be assigned to an MCO by the State in accordance with Section 2.4.4.6.
 
  2.4.4.3.2   Adults eligible for TennCare as a result of being eligible for SSI benefits will be assigned to an MCO (other than TennCare Select) by the State.
 
  2.4.4.3.3   Children eligible for TennCare as a result of being eligible for SSI will be assigned to TennCare Select (defined in Section 1 of this Agreement) but may opt-out of TennCare Select and choose another MCO.
 
  2.4.4.3.4   TennCare may allow enrollment of new TennCare enrollees in TennCare Select if there is insufficient capacity in other MCOs.
 
  2.4.4.4   Children in State Custody
 
      TennCare enrollees who are children in the custody of the Department of Children’s Services (DCS) will be enrolled in TennCare Select. When these enrollees exit state custody, they remain enrolled in TennCare Select for a specified period of time and then are disenrolled from TennCare Select. After disenrollment from TennCare Select, if the enrollee has a family member in an MCO (other than TennCare Select) he/she will be enrolled in that MCO. Otherwise, the enrollee will be given the opportunity to select another MCO. If the enrollee does not select another MCO, he/she will be assigned to an MCO (other than TennCare Select) using the default logic in the auto assignment process (see Section 2.4.4.6 below).
 
  2.4.4.5   Enrollment in MCO Other than the MCO Selected
 
      In certain circumstances, if an enrollee requests enrollment in a particular MCO, the enrollee may be assigned by the State to an MCO other than the one that he/she requested. Examples of circumstances when an enrollee would not be enrolled in the requested MCO include, but are not limited to, such factors as the enrollee does not reside in the Grand Region covered by the requested MCO, the enrollee has other family members already enrolled in a different MCO, the MCO is closed to new TennCare enrollment, or the enrollee is a member of a population that is to be enrolled in a specified MCO as defined by TENNCARE (e.g., children in the custody of the Department of Children’s Services are enrolled in TennCare Select).

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  2.4.4.6   Auto Assignment
 
  2.4.4.6.1   TENNCARE will auto assign an enrollee to an MCO, in specified circumstances, including but not limited to, the enrollee does not request enrollment in a specified MCO, cannot be enrolled in the requested MCO, or is an adult eligible as a result of receiving SSI benefits.
 
  2.4.4.6.2   The current auto assignment process does not apply to children eligible for TennCare as a result of being eligible for SSI or children in the state’s custody.
 
  2.4.4.6.3   There are four different levels to the current auto assignment process:
 
  2.4.4.6.3.1   If the enrollee was previously enrolled with an MCO and lost TennCare eligibility for a period of two (2) months or less, the enrollee will be re-enrolled with that MCO.
 
  2.4.4.6.3.2   If the enrollee has family members in an MCO (other than TennCare Select), the enrollee will be enrolled in that MCO.
 
  2.4.4.6.3.3   If the enrollee is a newborn, the enrollee will be assigned to his/her mother’s MCO.
 
  2.4.4.6.3.4   If none of the above applies, the enrollee will be assigned using default logic that randomly assigns enrollees to MCOs (other than TennCare Select).
 
  2.4.4.6.4   TENNCARE may modify the auto assignment algorithm to change or add criteria including but not limited to quality measures or cost or utilization management performance.
 
  2.4.4.7   Non-Discrimination
 
  2.4.4.7.1   The CONTRACTOR shall accept enrollees in the order in which applications are approved and enrollees are assigned to the CONTRACTOR (whether by selection or assignment).
 
  2.4.4.7.2   The CONTRACTOR shall accept an enrollee in the health condition the enrollee is in at the time of enrollment and shall not discriminate against individuals on the basis of health status or need for health care services.
 
  2.4.4.8   Family Unit
 
      If an individual is determined eligible for TennCare and has another family member already enrolled in an MCO, that individual shall be enrolled in the same MCO. This does not apply when the individual or family member is assigned to TennCare Select. If the newly enrolled family member opts to change MCOs during the 45-day change period (see Section 2.4.7.2.1), all family members in the case will be transferred to the new MCO.

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2.4.5 Effective Date of Enrollment
  2.4.5.1   Initial Enrollment of Current TennCare Enrollees
 
      The effective date of initial enrollment in an MCO for TennCare enrollees who are enrolled in accordance with Section 2.4.4.2 shall be the date provided on the enrollment file from TENNCARE. In general, the effective date of enrollment for these enrollees will be the start date of operations.
 
  2.4.5.2   Ongoing Enrollment
 
      In general, a member’s effective date of enrollment in the CONTRACTOR’s MCO will be the member’s effective date of eligibility for TennCare. For SSI enrollees the effective date of eligibility/enrollment is determined by the Social Security Administration in approving SSI coverage for the individual. The effective date of eligibility for other TennCare enrollees is the date of application or the date of the qualifying event (e.g., the date the spend down obligation is met for medically needy enrollees). The effective date on the enrollment file provided by TENNCARE to the CONTRACTOR shall govern regardless of the other provisions of this Section 2.4.5.2.
 
  2.4.5.3   In the event the effective date of eligibility provided by TENNCARE to the CONTRACTOR for either the initial enrollment of current TennCare enrollees or ongoing enrollment precedes the start date of operations, the CONTRACTOR shall treat the enrollee as a member of the CONTRACTOR’s MCO effective on the start date of operations. Although the enrollee is not a member of the CONTRACTOR’s MCO prior to the start date of operations, the CONTRACTOR shall be responsible for the payment of claims incurred by the enrollee during the period of eligibility prior to the start date of operations as specified in Section 3.7.1.2.1.
 
  2.4.5.4   TENNCARE will be responsible for the payment of claims for long-term care services provided to a CHOICES member during the member’s period of TennCare eligibility prior to the implementation of CHOICES in the Grand Region covered by this Agreement.
 
  2.4.5.5   Enrollment Prior to Notification
 
  2.4.5.5.1   Because individuals can be retroactively eligible for TennCare, and the effective date of initial enrollment in an MCO is the effective date of eligibility or start date of operations, whichever is sooner, the effective date of enrollment may occur prior to the CONTRACTOR being notified of the person’s enrollment. Therefore, enrollment of individuals in the CONTRACTOR’s MCO may occur without prior notice to the CONTRACTOR or enrollee.
 
  2.4.5.5.2   The CONTRACTOR shall not be liable for the cost of any covered services prior to the effective date of enrollment/eligibility but shall be responsible for the costs of covered services obtained on or after 12:01 a.m. on the effective date of enrollment/eligibility.
 
  2.4.5.5.3   TENNCARE shall make payments to the CONTRACTOR from the effective date of an enrollee’s date of enrollment/eligibility. If the effective date of

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      enrollment/eligibility precedes the start date of operations, payment shall be made in accordance with Section 3.7.1.2.1. TENNCARE will be responsible for the payment of claims for long-term care services provided to a CHOICES member during the member’s period of TennCare eligibility prior to the implementation of CHOICES in the Grand Region covered by this Agreement.
 
  2.4.5.5.4   Except for applicable TennCare cost sharing and patient liability, the CONTRACTOR shall ensure that members are held harmless for the cost of covered services provided as of the effective date of enrollment with the CONTRACTOR.
2.4.6 Eligibility and Enrollment Data
  2.4.6.1   The CONTRACTOR shall receive, process, and update enrollment files from TENNCARE. Enrollment data shall be updated or uploaded to the CONTRACTOR’s eligibility/enrollment database(s) within twenty-four (24) hours of receipt from TENNCARE.
 
  2.4.6.2   The CONTRACTOR shall provide an electronic eligibility file to TENNCARE as specified and in conformance to data exchange format and method standards outlined in Section 2.23.5.
2.4.7 Enrollment Period
  2.4.7.1   General
 
  2.4.7.1.1   The CONTRACTOR shall be responsible for the provision and costs of all covered physical health and behavioral health services provided to enrollees during their period of enrollment with the CONTRACTOR. The CONTRACTOR shall be responsible for the provision and costs of covered long-term care services provided to CHOICES members as of the date of CHOICES implementation.
 
  2.4.7.1.2   Enrollment shall begin at 12:0 1 a.m. on the effective date of enrollment in the CONTRACTOR’s MCO and shall end at 12:00 midnight on the date that the enrollee is disenrolled from the CONTRACTOR’s MCO (see Section 2.5).
 
  2.4.7.1.3   Once enrolled in the CONTRACTOR’s MCO, the member shall remain enrolled in the CONTRACTOR’s MCO until or unless the enrollee is disenrolled pursuant to Section 2.5 of this Agreement.
 
  2.4.7.2   Changing MCOs
 
  2.4.7.2.1   45-Day Change Period
 
      After becoming eligible for TennCare and enrolling in the CONTRACTOR’s MCO (whether the result of selection by the enrollee or assignment by TENNCARE), enrollees shall have one (1) opportunity, anytime during the forty-five (45) day period immediately following the date of enrollment with the CONTRACTOR’s MCO or the date TENNCARE sends the member notice of enrollment in an MCO, whichever is later, to request to change MCOs. Children eligible for TennCare as a result of being eligible for SSI may request to enroll in another MCO or remain with TennCare Select.

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  2.4.7.2.2   Annual Choice Period
 
  2.4.7.2.2.1   TENNCARE shall provide an opportunity for members to change MCOs (excluding TennCare Select) every twelve (12) months. Children eligible for TennCare as a result of being eligible for SSI may request to enroll in another MCO or remain with TennCare Select.
 
  2.4.7.2.2.2   Members who do not select another MCO will be deemed to have chosen to remain with their current MCO.
 
  2.4.7.2.2.3   Enrollees who select a new MCO shall have one (1) opportunity anytime during the forty-five (45) day period immediately following the specified enrollment effective date in the newly selected MCO to request to change MCOs.
 
  2.4.7.2.3   Appeal Based on Hardship Criteria
 
      As provided in TennCare rules and regulations, members may appeal to TENNCARE to change MCOs based on hardship criteria.
 
  2.4.7.2.4   Additional Reasons for Disenrollment
 
      As provided in Section 2.5.2, a member may be disenrolled from the CONTRACTOR’s MCO for the reasons specified therein.
 
  2.4.7.3   Member Moving out of Grand Region
 
      The CONTRACTOR shall be responsible for the provision and cost of all covered services for any member moving outside the CONTRACTOR’s Grand Region until the member is disenrolled by TENNCARE. TENNCARE shall continue to make payments to the CONTRACTOR on behalf of the enrollee until such time as the enrollee is enrolled in another MCO or otherwise disenrolled by TENNCARE (e.g., enrollee is terminated from the TennCare program). TENNCARE shall notify the CONTRACTOR promptly upon enrollment of the enrollee in another MCO.
2.4.8 Transfers from Other MCOs
  2.4.8.1   The CONTRACTOR shall accept enrollees (enrolled or pending enrollment) from any MCO in the CONTRACTOR’s service area as authorized by TENNCARE. The transfer of membership may occur at any time during the year. No enrollee from another MCO shall be transferred retroactively to the CONTRACTOR except as specified in Section 2.4.9. Except as provided in Section 2.4.9, the CONTRACTOR shall not be responsible for payment of any covered services incurred by enrollees transferred to the CONTRACTOR prior to the effective date of transfer to the CONTRACTOR.
 
  2.4.8.2   Transfers from other MCOs shall be in consideration of the maximum enrollment levels established in Section 2.4.3.
 
  2.4.8.3   To the extent possible and practical, TENNCARE shall provide advance notice to all MCOs serving a Grand Region of the impending failure of one of the MCOs serving

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      the Grand Region; however, failure by TENNCARE to provide advance notice shall not limit in any manner the responsibility of each MCO to accept enrollees from failed MCOs.
2.4.9 Enrollment of Newborns
  2.4.9.1   TennCare-eligible newborns and their mothers, to the extent that the mother is eligible for TennCare, should be enrolled in the same MCO with the exception of newborns that are SSI eligible at birth. Newborns that are SSI eligible at birth shall be assigned to TennCare Select but may opt out and enroll in another MCO.
 
  2.4.9.2   A newborn may be inadvertently enrolled in an MCO different than its mother. When such cases are identified by the CONTRACTOR, the CONTRACTOR shall immediately report to TENNCARE, in accordance with written procedures provided by TENNCARE, that a newborn has been incorrectly enrolled in an MCO different than its mother.
 
  2.4.9.3   Upon receipt of notice from the CONTRACTOR or discovery by TENNCARE that a newborn has been incorrectly enrolled in an MCO different than its mother, TENNCARE shall immediately:
 
  2.4.9.3.1   Disenroll the newborn from the incorrect MCO;
 
  2.4.9.3.2   Enroll the newborn in the same MCO as its mother with the same effective date as when the newborn was enrolled in the incorrect MCO;
 
  2.4.9.3.3   Recoup any payments made to the incorrect MCO for the newborn; and
 
  2.4.9.3.4   Make payments only to the correct MCO for the period of coverage.
 
  2.4.9.4   The MCO in which the newborn is correctly enrolled shall be responsible for the coverage and payment of covered services provided to the newborn for the full period of eligibility. Except as provided below, the MCO in which the newborn was incorrectly enrolled shall have no liability for the coverage or payment of any services during the period of incorrect MCO assignment. TENNCARE shall only be liable for the capitation payment to the correct MCO.
 
  2.4.9.5   There are circumstances in which a newborn’s mother may not be eligible for participation in the TennCare program. The CONTRACTOR shall be required to process claims received for services provided to newborns within the time frames specified in Section 2.22.4 of this Agreement. A CONTRACTOR shall not utilize any blanket policy which results in the automatic denial of claims for services provided to a TennCare-eligible newborn, during any period of enrollment in the CONTRACTOR’s MCO, because the newborn’s mother is not a member of the CONTRACTOR’s MCO. However, it is recognized that in complying with the claims processing time frames specified in 2.22.4 of this Agreement, a CONTRACTOR may make payment for services provided to a TennCare-eligible newborn enrolled in the CONTRACTOR’s MCO at the time of payment but the newborn’s eligibility may subsequently be moved to another MCO. In such event, the MCO in which the newborn is first enrolled (first MCO) may submit supporting documentation to the MCO in which the newborn is moved (second MCO) and the

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      second MCO shall reimburse the first MCO within thirty (30) calendar days of receipt of such properly documented request for reimbursement, for the amount expended on behalf of the newborn prior to the newborn’s eligibility having been moved to the second MCO. Such reimbursement shall be the actual amount expended by the first MCO. The second MCO agrees that should the second MCO fail to reimburse the first MCO the actual amount expended on behalf of the newborn within thirty (30) calendar days of receipt of a properly documented request for payment, TENNCARE is authorized to deduct the amount owed from any funds due the second MCO and to reimburse the first MCO. In the event that the CONTRACTOR fails to reimburse the first MCO the actual amount expended on behalf of the newborn within thirty (30) calendar days of receipt of a properly documented request for payment, TENNCARE may assess liquidated damages as specified in Section 4.20.2. Should it become necessary for TENNCARE to intervene in such cases, both the second MCO and the first MCO agree that TENNCARE shall be held harmless by both MCOs for actions taken by TENNCARE to resolve the dispute.
2.4.10 Information Requirements Upon Enrollment
    As described in Section 2.17 of this Agreement, the CONTRACTOR shall provide the following information to new members: a member handbook, a provider directory and an identification card. In addition, the CONTRACTOR shall provide CHOICES members with CHOICES member education materials (see Section 2.17.7).
 
6.   Section 2.5.2 shall be amended by adding a new Section 2.5.2.3 and renumbering existing subparts accordingly, including any references thereto.
  2.5.2.3   A request by the member to change MCOs based on hardship criteria (pursuant to TennCare rules and regulations) is approved by TENNCARE, and the member is enrolled in another MCO;
7.   Section 2.5.5 shall be amended by adding “from an MCO” to the end of the heading to read as follows:
  2.5.5   Effective Date of Disenrollment from an MCO
8.   Section 2.6 shall be deleted in its entirety and replaced with the following:
   
2.6   BENEFITS/SERVICE REQUIREMENTS AND LIMITS
2.6.1 CONTRACTOR Covered Benefits
  2.6.1.1   The CONTRACTOR shall cover the physical health, behavioral health and long-term care services/benefits outlined below. Additional requirements for behavioral health services are included in Section 2.7.2 and Attachment I.
 
  2.6.1.2   The CONTRACTOR shall integrate the delivery of physical health, behavioral health and long-term care services. This shall include but not be limited to the following:

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  2.6.1.2.1   The CONTRACTOR shall operate a member services toll-free phone line (see Section 2.18.1) that is used by all members, regardless of whether they are calling about physical health, behavioral health and/or long-term care services. The CONTRACTOR shall not have a separate number for members to call regarding behavioral health and/or long-term care services. The CONTRACTOR may either route the call to another entity or conduct a “warm transfer” to another entity, but the CONTRACTOR shall not require an enrollee to call a separate number regarding behavioral health and/or long-term care services.
 
  2.6.1.2.2   If the CONTRACTOR’s nurse triage/nurse advice line is separate from its member services line, the CONTRACTOR shall comply with the requirements in Section 2.6.1.2.2 as applied to the nurse triage/nurse advice line. The number for the nurse triage/nurse advice line shall be the same for all members, regardless of whether they are calling about physical health, behavioral health and/or long-term services, and the CONTRACTOR may either route calls to another entity or conduct “warm transfers,” but the CONTRACTOR shall not require an enrollee to call a separate number.
 
  2.6.1.2.3   As required in Sections 2.9.5 and 2.9.6, the CONTRACTOR shall ensure continuity and coordination among physical health, behavioral health, and long-term care services and ensure collaboration among physical health, behavioral health, and long-term care providers. For CHOICES members, the member’s care coordinator shall ensure continuity and coordination of physical health, behavioral health, and long-term care services, and facilitate communication and ensure collaboration among physical health, behavioral health, and long-term care providers.
 
  2.6.1.2.4   Each of the CONTRACTOR’s disease management programs (see Section 2.8) shall address the needs of members who have co-morbid physical health and behavioral health conditions.
 
  2.6.1.2.5   As required in Section 2.9.5.2.2, the CONTRACTOR shall provide MCO case management to non-CHOICES members with co-morbid physical health and behavioral health conditions. These members should have a single case manager that is trained to provide MCO case management to enrollees with co-morbid physical health and behavioral health conditions. If a member with co-morbid physical and behavioral health conditions does not have a single case manager, the CONTRACTOR shall ensure, at a minimum, that the member’s MCO case managers collaborate and communicate in an effective and ongoing manner. As required in Section 2.9.6.1.8 of this Agreement, the CONTRACTOR shall ensure that upon enrollment into CHOICES, MCO case management activities are integrated with CHOICES care coordination processes and functions, and that the member’s assigned care coordinator has primary responsibility for coordination of all the member’s physical health, behavioral health, and long-term care needs. The member’s care coordinator may use resources and staff from the CONTRACTOR’s case management program, including persons with specialized expertise in areas such as behavioral health, to supplement but not supplant the role and responsibilities of the member’s care coordinator/care coordination team. The CONTRACTOR shall report on its case management activities per requirements in Section 2.30.6.1.

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  2.6.1.2.6   If the CONTRACTOR uses different Systems for physical health services, behavioral health and/or long-term care services, these systems shall be interoperable. In addition, the CONTRACTOR shall have the capability to integrate data from the different systems.
 
  2.6.1.2.7   The CONTRACTOR’s administrator/project director (see Section 2.29.1.3.1) shall be the primary contact for TENNCARE regarding all issues, regardless of the type of service, and shall not direct TENNCARE to other entities. The CONTRACTOR’s administrator/project director shall coordinate with the CONTRACTOR’s senior executive psychiatrist who oversees behavioral health activities (see Section 2.29.1.3.4 of this Agreement) for all behavioral health issues and the senior executive responsible for CHOICES activities (see Section 2.29.1.3.5 of this Agreement) for all issues pertaining to the CHOICES program.
 
  2.6.1.3   CONTRACTOR Physical Health Benefits Chart
     
SERVICE   BENEFIT LIMIT
Inpatient
Hospital
Services
  Medicaid/Standard Eligible, Age 21 and older: As medically necessary. Inpatient rehabilitation hospital facility services are not covered for adults unless determined by the CONTRACTOR to be a cost effective alternative (see Section 2.6.5).
 
   
 
  Medicaid/Standard Eligible, Under age 21: As medically necessary, including rehabilitation hospital facility.
 
   
Outpatient
Hospital
Services
  As medically necessary.
 
   
Physician
Inpatient
Services
  As medically necessary.
 
   
Physician
Outpatient
Services/Community
Health Clinic
Services/Other Clinic
Services
  As medically necessary.

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SERVICE   BENEFIT LIMIT
TENNderCare
Services
  Medicaid/Standard Eligible, Age 21 and older: Not covered.
 
   
 
  Medicaid/Standard Eligible, Under age 21: Covered as medically necessary, except that the screenings do not have to be medically necessary. Children may also receive screenings in-between regular checkups if a parent or caregiver believes there is a problem.
 
   
 
  Screening, interperiodic screening, diagnostic and follow-up treatment services as medically necessary in accordance with federal and state requirements. See Section 2.7.6.
   
Preventive Care
Services
  As described in Section 2.7.5.
 
   
Lab and X-ray
Services
  As medically necessary.
 
   
Hospice
Care
  As medically necessary. Shall be provided by a Medicare-certified hospice.
 
   
Dental Services
  Dental Services shall be provided by the Dental Benefits Manager.
 
   
 
  However, the facility, medical and anesthesia services related to the dental service that are not provided by a dentist or in a dentist’s office shall be covered services provided by the CONTRACTOR when the dental service is covered by the DBM. This requirement only applies to Medicaid/Standard Eligibles Under age 21.
 
   
Vision
  Medicaid/Standard Eligible, Age 21 and older:
Services
  Medical eye care, meaning evaluation and management of abnormal conditions, diseases, and disorders of the eye (not including evaluation and treatment of refractive state), shall be covered as medically necessary. Routine periodic assessment, evaluation, or screening of normal eyes and examinations for the purpose of prescribing fitting or changing eyeglass and/or contact lenses are not covered. One pair of cataract glasses or lenses is covered for adults following cataract surgery.
 
   
 
  Medicaid/Standard Eligible, Under age 21 :
 
  Preventive, diagnostic, and treatments services (including eyeglasses) are covered as medically necessary in accordance with TENNderCare requirements.

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SERVICE   BENEFIT LIMIT
Home Health
  Medicaid /Standard Eligible, Age 21 and older:
Care
  Covered as medically necessary and in accordance with the definition of Home Health Care at Rule 1200-13-13-.01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard).
 
   
 
  Medicaid/Standard Eligible, Under age 21:
 
  Covered as medically necessary in accordance with the definition of Home Health Care at Rule 1200-13-13-.01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard).
 
   
Pharmacy
Services
  Pharmacy services shall be provided by the Pharmacy Benefits Manager (PBM), unless otherwise described below.
 
   
 
  The CONTRACTOR shall be responsible for reimbursement of injectable drugs obtained in an office/clinic setting and to providers providing both home infusion services and the drugs and biologics. The CONTRACTOR shall require that all home infusion claims contain National Drug Code (NDC) coding and unit information to be paid.
 
   
 
  Services reimbursed by the CONTRACTOR shall not be included in any pharmacy benefit limits established by TENNCARE for pharmacy services (see Section 2.6.2.2).
 
   
Durable Medical
Equipment (DME)
  As medically necessary.
 
   
 
  Specified DME services shall be covered/non-covered in accordance with TennCare rules and regulations.
 
   
Medical
Supplies
  As medically necessary.
 
   
 
  Specified medical supplies shall be covered/non-covered in accordance with TennCare rules and regulations.
 
   
Emergency Air And
Ground Ambulance
Transportation
  As medically necessary.
 
   
Non-emergency
Medical
Transportation
(including Non-
Emergency
  Covered non-emergency medical transportation (NEMT) services are necessary non-emergency transportation services provided to convey members to and from TennCare covered services (see definition in Exhibit A to Attachment XI). Non emergency transportation services

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SERVICE   BENEFIT LIMIT
Ambulance
Transportation)
  shall be provided in accordance with federal law and the Bureau of TennCare’s rules and policies and procedures. TennCare covered services (see definition in Exhibit A to Attachment XI) include services provided to a member by a non-contract or non-TennCare provider if (a) the service is covered by Tennessee’s Medicaid State Plan or Section 1115 demonstration waiver, (b) the provider could be a TennCare provider for that service, and (c) the service is covered by a third party resource (see definition in Section 1 of the Agreement).
 
   
 
  If a member requires assistance, an escort (as defined in TennCare rules and regulations) may accompany the member; however, only one (1) escort is allowed per member (see TennCare rules and regulations). Except for fixed route and commercial carrier transport, the CONTRACTOR shall not make separate or additional payment to a NEMT provider for an escort. Covered NEMT services include having an accompanying adult ride with a member if the member is under age eighteen (18). Except for fixed route and commercial carrier transport, the CONTRACTOR shall not make separate or additional payment to a NEMT provider for an adult accompanying a member under age eighteen (18).
 
   
 
  The CONTRACTOR is not responsible for providing NEMT to HCBS, including services provided through a 1915(c) waiver program for persons with mental retardation and HCBS provided through the CHOICES program. However, as specified in Section 2.11.1.8 in the event the CONTRACTOR is unable to meet the access standard for adult day care (see Attachment III), the CONTRACTOR shall provide and pay for the cost of transportation for the member to the adult day care facility until such time the CONTRACTOR has sufficient provider capacity.
 
   
 
  Mileage reimbursement, car rental fees, or other reimbursement for use of a private automobile (as defined in Exhibit A to Attachment XI) is not a covered NEMT service.
 
   
 
  If the member is a child, transportation shall be provided in accordance with TENNderCare requirements (see Section 2.7.6.4.6).
 
   
 
  Failure to comply with the provisions of this Section may result in liquidated damages.

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SERVICE   BENEFIT LIMIT
Renal Dialysis
Services
  As medically necessary.
 
   
Private Duty
  Medicaid/Standard Eligible, Age 21 and older:
Nursing
  Covered as medically necessary in accordance with the definition of Private Duty Nursing at Rule 1200-13-13-.01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard), when prescribed by an attending physician for treatment and services rendered by a Registered Nurse (R.N.) or a licensed practical nurse (L.P.N.) who is not an immediate relative. Private duty nursing services are limited to services that support the use of ventilator equipment or other life sustaining technology when constant nursing supervision, visual assessment, and monitoring of both equipment and patient are required. Prior authorization required, as described Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200- 13-14-.04 (for TennCare Standard).
 
   
 
  Medicaid/Standard Eligible, Under age 21:
 
  Covered as medically necessary in accordance with the definition of Private Duty Nursing at Rule 1200-13-13-.01 (for TennCare Medicaid) and 1200-13-14-.01 (for TennCare Standard) when prescribed by an attending physician for treatment and services rendered by a registered nurse (R.N.) or a licensed practical nurse (L.P.N.), who is not an immediate relative. Prior authorization required as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard).
 
   
Speech
  Medicaid/Standard Eligible, Age 21 and older:
Therapy
  Covered as medically necessary by a Licensed Speech Therapist to restore speech (as long as there is continued medical progress) after a loss or impairment. The loss or impairment must not be caused by a mental, psychoneurotic or personality disorder.
 
   
 
  Medicaid/Standard Eligible, Under age 21:
 
  Covered as medically necessary in accordance with TENNderCare requirements.
 
   
Occupational
  Medicaid/Standard Eligible, Age 21 and older:
Therapy
  Covered as medically necessary when provided by a Licensed Occupational Therapist to restore, improve, or stabilize impaired functions.
 
   
 
  Medicaid/Standard Eligible, Under age 21:
 
  Covered as medically necessary in accordance with TENNderCare requirements.

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SERVICE   BENEFIT LIMIT
Physical
  Medicaid/Standard Eligible, Age 21 and older:
Therapy
  Covered as medically necessary when provided by a Licensed Physical Therapist to restore, improve, or stabilize impaired functions.
 
   
 
  Medicaid Standard Eligible, Under age 21: Covered as medically necessary in accordance with TENNderCare requirements.
 
   
Organ and Tissue
Transplant
And Donor Organ
Procurement
  Medicaid/Standard Eligible, Age 21 and older: All medically necessary and non-investigational/experimental organ and tissue transplants, as covered by Medicare, are covered. These include, but may not be limited to:
 
  Bone marrow/Stem cell;
 
  Cornea;
 
  Heart;
 
  Heart/Lung;
 
  Kidney;
 
  Kidney/ Pancreas;
 
  Liver;
 
  Lung;
 
  Pancreas; and
 
  Small bowel/Multi-visceral.
 
   
 
  Medicaid/Standard Eligible, Under age 21: Covered as medically necessary in accordance with TENNderCare requirements. Experimental or investigational transplants are not covered.
 
   
Reconstructive Breast
Surgery
  Covered in accordance with TCA 56-7-2507, which requires coverage of all stages of reconstructive breast surgery on a diseased breast as a result of a mastectomy, as well as surgical procedures on the non-diseased breast to establish symmetry between the two breasts in the manner chosen by the physician. The surgical procedure performed on a non-diseased breast to establish symmetry with the diseased breast shall only be covered if the surgical procedure performed on a non-diseased breast occurs within five (5) years of the date the reconstructive breast surgery was performed on a diseased breast.
 
   
Chiropractic
Services
  Medicaid/Standard Eligible, Age 21 and older: Not covered unless determined by the CONTRACTOR to be a cost effective alternative (see Section 2.6.5).
 
   
 
  Medicaid/Standard Eligible, Under age 21: Covered as medically necessary in accordance with TENNderCare requirements.

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2.6.1.4 CONTRACTOR Behavioral Health Benefits Chart
     
SERVICE   BENEFIT LIMIT
Psychiatric Inpatient
Hospital
Services (including
physician services)
  As medically necessary.
 
   
24-hour Psychiatric
Residential Treatment
  Medicaid/Standard Eligible, Age 21 and older: As medically necessary.
 
   
 
  Medicaid/Standard Eligible, Under age 21: Covered as medically necessary.
 
   
Outpatient Mental
Health Services
(including physician
services)
  As medically necessary.
 
   
Inpatient, Residential
& Outpatient
Substance Abuse
Benefits
1
  Medicaid/Standard Eligible, Age 21 and older: Limited to ten (10) days detox, $30,000 in medically necessary lifetime benefits unless otherwise described in the 2008 Mental Health Parity Act as determined by TENNCARE.
 
   
 
  Medicaid/Standard Eligible, Under age 21: Covered as medically necessary.
 
   
Mental Health Case
Management
  As medically necessary.
 
   
Psychiatric-
Rehabilitation
Services
  As medically necessary.
 
   
Behavioral Health
Crisis Services
  As necessary.
 
   
Lab and X-ray
Services
  As medically necessary.
 
   
Non-emergency
Medical
Transportation
(including Non-
Emergency
Ambulance
Transportation)
  Same as for physical health (see Section 2.6.1.3 above).
 
1   When medically appropriate, services in a licensed substance abuse residential treatment facility may be substituted for inpatient substance abuse services. Methadone clinic services are not covered for adults.
  2.6.1.5   Long-Term Care Benefits for CHOICES Members
 
  2.6.1.5.1   In addition to physical health benefits (see Section 2.6.1.3) and behavioral health benefits (see Section 2.6.1.4), the CONTRACTOR shall provide long-term care services (including HCBS and nursing facility care) as described in this Section 2.6.1.5 to members who have been enrolled into CHOICES by TENNCARE, as shown in the enrollment file furnished by TENNCARE to the CONTRACTOR, effective upon the CHOICES Implementation Date (see Section 1).

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  2.6.1.5.2   TennCare enrollees will be enrolled by TENNCARE into CHOICES if the following conditions, at a minimum, are met:
  2.6.1.5.2.1   TENNCARE or its designee determines the enrollee meets the categorical and financial eligibility criteria for Group 1, 2 or 3;
 
  2.6.1.5.2.2   For Groups 1 and 2, TENNCARE determines that the enrollee meets nursing facility level of care;
 
  2.6.1.5.2.3   For Group 2, the CONTRACTOR or, for new TennCare applicants, TENNCARE or its designee, determines that the enrollee’s combined HCBS, private duty nursing and home health care can be safely provided at a cost less than the cost of nursing facility care for the member;
 
  2.6.1.5.2.4   For Group 3, TENNCARE determines that the enrollee meets the at-risk level of care; and
 
  2.6.1.5.2.5   For Groups 2 and 3, if there is an enrollment target, TENNCARE determines that the enrollment target has not been met or, for Group 2, approves the CONTRACTOR’s request to provide HCBS as a cost effective alternative (see Section 2.6.5). Enrollees transitioning from a nursing facility to the community will not be subject to the enrollment target for Group 2 but must meet categorical and financial eligibility for Group 2.
  2.6.1.5.3   For persons determined to be eligible for enrollment in Group 2 as a result of Immediate Eligibility (as defined in Section 1 of this Agreement), the CONTRACTOR shall provide a limited package of HCBS (personal care, attendant care, homemaker services, home-delivered meals, PERS, adult day care, and/or any other services as specified in TennCare rules and regulations) as identified through a needs assessment and specified in the plan of care. Upon notice that the State has determined that the member meets categorical and financial eligibility for TennCare CHOICES, the CONTRACTOR shall authorize additional services in accordance with Section 2.9.6.2.5. For members residing in a community-based residential alternative at the time of CHOICES enrollment, authorization for community-based residential alternative services shall be retroactive to the member’s effective date of CHOICES enrollment.
 
  2.6.1.5.4   The following long-term care services are available to CHOICES members, per Group, when the services have been determined medically necessary by the CONTRACTOR.
             
Service and Benefit Limit   Group 1   Group 2   Group 3
Nursing facility care
  X   Short-term only (up to 90 days)   Short-term only
(up to 90 days)
 
           
Community-based
residential alternatives
      X    
 
           
Personal care visits (up to 2 visits per day)
      X   X

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Service and Benefit Limit   Group 1   Group 2   Group 3
Attendant care (up to 1080 hours per calendar year)
      X   X
 
           
Homemaker services (up to 3 visits per week)
      X   X
 
           
Home-delivered meals (up to 1 meal per day)
      X   X
 
           
Personal Emergency Response Systems
      X   X
 
           
Adult day care (up to 2080 hours per calendar year)
      X   X
 
           
In-home respite care (up to 216 hours per calendar year)
      X   X
 
           
In-patient respite care (up to 9 days per calendar year)
      X   X
 
           
Assistive technology (up to $900 per calendar year)
      X   X
 
           
Minor home modifications (up to $6,000 per project; $10,000 per calendar year; and $20,000 per lifetime)
      X   X
 
           
Pest control (up to 9 units per calendar year)
      X   X
  2.6.1.5.5   In addition to the benefit limits described above, in no case shall the CONTRACTOR exceed the cost neutrality cap for CHOICES Group 2 or the expenditure cap for Group 3. For CHOICES members in Group 2, the total cost of HCBS, home health care and private duty nursing shall not exceed a member’s cost neutrality cap (as defined in Section 1 of this Agreement). For CHOICES members in Group 3, the total cost of HCBS, excluding minor home modifications, shall not exceed the expenditure cap (as defined in Section 1 of this Agreement).
 
  2.6.1.5.6   CHOICES members may, pursuant to Section 2.9.7, choose to participate in consumer direction of HCBS and, at a minimum, hire, fire and supervise workers of eligible HCBS.
 
  2.6.1.5.7   The CONTRACTOR shall monitor CHOICES members’ receipt and utilization of long-term care services, identify CHOICES members who have not received long-term care services within a thirty (30) day period of time, and notify TENNCARE regarding these members pursuant to Section 2.30.10.5. TENNCARE will investigate to determine if the member should remain enrolled in CHOICES.
 
  2.6.1.5.8   The CONTRACTOR may submit to TENNCARE a request to no longer provide long-term care services to a member due to concerns regarding the ability to safely and effectively care for the member in the community and/or to ensure the member’s health, safety and welfare. Acceptable reasons for this request include but are not limited to the following:

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  2.6.1.5.8.1   A member in Group 2 or 3 for whom the CONTRACTOR has determined that it cannot safely and effectively meet the member’s needs at a cost that is less than the member’ cost neutrality cap, and the member declines to transition to a nursing facility;
 
  2.6.1.5.8.2   A member in Group 2 or 3 who repeatedly refuses to allow a care coordinator entrance into his/her place of residence (Section 2.9.6);
 
  2.6.1.5.8.3   A member in Group 2 or 3 who refuses to receive critical HCBS as identified through a needs assessment and documented in the member’s plan of care; and
 
  2.6.1.5.8.4   A member in Group 1 who fails to pay his/her patient liability and the CONTRACTOR is unable to find a nursing facility willing to provide services to the member (Section 2.6.7.2).
 
  2.6.1.5.8.5   The CONTRACTOR’s request to no longer provide long-term care services to a member shall include documentation as specified by TENNCARE. The State shall make any and all determinations regarding whether the CONTRACTOR may discontinue providing long-term care services to a member, disenrollment from CHOICES, and, as applicable, termination from TennCare.
2.6.2 TennCare Benefits Provided by TENNCARE
TennCare shall be responsible for the payment of the following benefits:
  2.6.2.1   Dental Services
 
      Except as provided in Section 2.6.1.3 of this Agreement, dental services shall not be provided by the CONTRACTOR but shall be provided by a dental benefits manager (DBM) under contract with TENNCARE. Coverage of dental services is described in TennCare rules and regulations.
 
  2.6.2.2   Pharmacy Services
 
      Except as provided in Section 2.6.1.3 of this Agreement, pharmacy services shall not be provided by the CONTRACTOR but shall be provided by a pharmacy benefits manager (PBM) under contract with TENNCARE. Coverage of pharmacy services is described in TennCare rules and regulations. TENNCARE does not cover pharmacy services for enrollees who are dually eligible for TennCare and Medicare.
 
  2.6.2.3   ICF/MR Services and Alternatives to ICF/MR Services
 
      For qualified enrollees in accordance with TennCare policies and/or TennCare rules and regulations, TENNCARE covers the costs of long-term care institutional services in an Intermediate Care Facility for the Mentally Retarded (ICF/MR) or alternative to an ICF/MR provided through a Home and Community Based Services (HCBS) waiver for persons with MR.

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2.6.3 Medical Necessity Determination
  2.6.3.1   The CONTRACTOR may establish procedures for the determination of medical necessity. The determination of medical necessity shall be made on a case by case basis and in accordance with the definition of medical necessity defined in TCA 71- 5-144 and TennCare rules and regulations. However, this requirement shall not limit the CONTRACTOR’s ability to use medically appropriate cost effective alternatives in accordance with Section 2.6.5.
 
  2.6.3.2   The CONTRACTOR shall not employ, and shall not permit others acting on their behalf to employ, utilization control guidelines or other quantitative coverage limits, whether explicit or de facto, unless supported by an individualized determination of medical necessity based upon the needs of each TennCare enrollee and his/her medical history. The CONTRACTOR shall have the ability to place tentative limits on a service; however, such tentative limits placed by the CONTRACTOR shall be exceeded (up to the applicable benefit limits on behavioral health and long-term care services provided in Section 2.6.1.4 and 2.6.1.5 above) when medically necessary based on a member’s individual characteristics.
 
  2.6.3.3   The CONTRACTOR shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition.
 
  2.6.3.4   The CONTRACTOR may deny services that are non-covered except as otherwise required by TENNderCare or unless otherwise directed to provide by TENNCARE and/or an administrative law judge.
 
  2.6.3.5   All medically necessary services shall be covered for enrollees under twenty-one (21) years of age in accordance with TENNderCare requirements (see Section 2.7.6).
2.6.4 Second Opinions
The CONTRACTOR shall provide for a second opinion in any situation where there is a question concerning a diagnosis or the options for surgery or other treatment of a health condition when requested by a member, parent and/or legally appointed representative. The second opinion shall be provided by a contracted qualified health care professional or the CONTRACTOR shall arrange for a member to obtain one from a non-contract provider. The second opinion shall be provided at no cost to the member.
2.6.5 Use of Cost Effective Alternative Services
  2.6.5.1   The CONTRACTOR shall be allowed to use cost effective alternative services, whether listed as covered or non-covered or omitted in Section 2.6.1 of this Agreement, when the use of such alternative services is medically appropriate and is cost effective. This may include, for example, use of nursing facilities as step down alternatives to acute care hospitalization or hotel accommodations for persons on outpatient radiation therapy to avoid the rigors of daily transportation. The CONTRACTOR shall comply with TennCare policies and procedures. As provided in the applicable TennCare policies and procedures, services not listed in the TennCare policies and procedures must be prior approved in writing by TENNCARE.

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  2.6.5.2   For CHOICES members, the CONTRACTOR may choose to provide the following as a cost effective alternative to other covered services:
  2.6.5.2.1   HCBS to CHOICES members who would otherwise receive nursing facility care. If a member meets categorical and financial eligibility requirements for enrollment in Group 2 and also meets the nursing facility level of care, as determined by TENNCARE, and would otherwise remain in or be admitted to a nursing facility (as determined by the CONTRACTOR and demonstrated to the satisfaction of TENNCARE), the CONTRACTOR may, at its discretion and upon TENNCARE written prior approval, offer that member HCBS as a cost effective alternative to nursing facility care (see Section 2.9.6.3.13). In this instance, TENNCARE will enroll the member receiving HCBS as a cost effective alternative to nursing facility services in Group 2, notwithstanding any enrollment target for Group 2 that has been reached.
 
  2.6.5.2.2   HCBS to CHOICES members in Group 2 in excess of the benefit limits described in Section 2.6.1.5.4 as a cost effective alternative to nursing facility care or covered home health services.
 
  2.6.5.2.3   HCBS to CHOICES members in Group 3 in excess of the benefit limits described in Section 2.6.1.5.4 as a cost effective alternative to covered home health services. Members in Group 3 do not meet nursing facility level of care and as such, HCBS in excess of benefit limits specified in Section 2.6.1.5.4 may not be offered as a cost effective alternative to nursing facility care.
 
  2.6.5.2.4   Non-covered HCBS services to CHOICES members in Group 2 not otherwise specified in this Agreement or in applicable TennCare policies and procedures, upon written prior approval from TENNCARE.
 
  2.6.5.2.5   For CHOICES members transitioning from a nursing facility to a community setting, a one-time transition allowance, per member. The amount of the transition allowance shall not exceed two thousand dollars ($2,000) and may be used for items such as, but not limited to, the first month’s rent and/or utility deposits, kitchen appliances, furniture, and basic household items.
 
  2.6.5.2.6   For CHOICES members in Groups 2 or 3, non-emergency medical transportation (NEMT) not otherwise covered by this Agreement.
 
  2.6.5.3   If the CONTRACTOR chooses to provide cost effective alternative services to a CHOICES member, in no case shall the cost of HCBS, private duty nursing and home health care for Group 2 exceed a member’s cost neutrality cap nor the total cost of HCBS, excluding minor home modifications, for members in Group 3 exceed the expenditure cap. The total cost of HCBS includes all HCBS (whether otherwise covered or not covered) and other services that are offered as a cost effective alternative to nursing facility care, HCBS, or home health, including, as applicable, the one-time transition allowance for Group 2 and NEMT for Groups 2 and 3.

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2.6.6 Additional Services and Use of Incentives
  2.6.6.1   The CONTRACTOR shall not advertise any services that are not required by this Agreement other than those covered pursuant to Section 2.6.1 of this Agreement.
 
  2.6.6.2   The CONTRACTOR shall not offer or provide any services other than services covered by this Agreement (see Section 2.6.1) or services provided as a cost effective alternative (see Section 2.6.5) of this Agreement. However, the CONTRACTOR may provide incentives that have been specifically prior approved in writing by TENNCARE. For example, TENNCARE may approve the use of incentives given to enrollees to encourage participation in disease management programs.
2.6.7 Cost Sharing and Patient Liability
  2.6.7.1   General
 
      The CONTRACTOR and all providers and subcontractors shall not require any cost sharing or patient liability responsibilities for covered services except to the extent that cost sharing or patient liability responsibilities are required for those services by TENNCARE in accordance with TennCare rules and regulations, including but not limited to, holding enrollees liable for debt due to insolvency of the CONTRACTOR or non-payment by the State to the CONTRACTOR. Further, the CONTRACTOR and all providers and subcontractors shall not charge enrollees for missed appointments.
 
  2.6.7.2   Patient Liability
 
  2.6.7.2.1   TENNCARE will notify the CONTRACTOR of any applicable patient liability amounts for CHOICES members in Group 1 via the eligibility/enrollment file. The CONTRACTOR shall delegate collection of patient liability to the nursing facility and shall pay the facility net of the applicable patient liability amount.
 
  2.6.7.2.2   In accordance with the involuntary discharge process, including notice and appeal (see Section 2.12.11.3), a nursing facility may refuse to continue providing services to a member who fails to pay his or her patient liability and for whom the nursing facility can demonstrate to the CONTRACTOR that it has made a good faith effort to collect payment.
 
  2.6.7.2.3   If the CONTRACTOR is notified that a nursing facility is considering discharging a member (see Section 2.12.11.3), the CONTRACTOR shall work to find an alternate nursing facility willing to serve the member and document its efforts in the member’s files.
 
  2.6.7.2.4   If the CONTRACTOR is unable to find an alternate nursing facility willing to serve the member, the CONTRACTOR shall determine if it can safely and effectively serve the member in the community and within the cost neutrality cap. If it can, the member shall be offered a choice of HCBS. If the member chooses HCBS, the CONTRACTOR shall forward all relevant information to TENNCARE for a decision regarding enrollment in Group 2 (Section 2.9.6.3).

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  2.6.7.2.5   If the CONTRACTOR is unable to find an alternate nursing facility willing to serve the member and the CONTRACTOR determines that it cannot safely and effectively serve the member in the community and within the cost neutrality cap, the member declines to enroll in Group 2, or TENNCARE denies enrollment in Group 2, the CONTRACTOR may, pursuant to Section 2.6.1.5.8, request to no longer provide long-term care services to the member.
 
  2.6.7.3   Preventive Services
 
      TennCare cost sharing or patient liability responsibilities shall apply to covered services other than the preventive services described in TennCare rules and regulations.
 
  2.6.7.4   Cost Sharing Schedule
 
      The current TennCare cost sharing schedule is included in this Agreement as Attachment II. The CONTRACTOR shall not waive or use any alternative cost sharing schedules, unless required by TENNCARE.
 
  2.6.7.5   Provider Requirements
 
  2.6.7.5.1   Providers or collection agencies acting on the provider’s behalf may not bill enrollees for amounts other than applicable TennCare cost sharing or patient liability amounts for covered services, including but not limited to, services that the State or the CONTRACTOR has not paid for, except as permitted by TennCare rules and regulations and as described below. Providers may seek payment from an enrollee only in the following situations.
 
  2.6.7.5.1.1   If the services are not covered services and, prior to providing the services, the provider informed the enrollee that the services were not covered. The provider shall inform the enrollee of the non-covered service and have the enrollee acknowledge the information. If the enrollee still requests the service, the provider shall obtain such acknowledgment in writing prior to rendering the service. Regardless of any understanding worked out between the provider and the enrollee about private payment, once the provider bills an MCO for the service that has been provided, the prior arrangement with the enrollee becomes null and void without regard to any prior arrangement worked out with the enrollee.
 
  2.6.7.5.1.2   If the enrollee’s TennCare eligibility is pending at the time services are provided and if the provider informs the person they will not accept TennCare assignment whether or not eligibility is established retroactively. Regardless of any understanding worked out between the provider and the enrollee about private payment, once the provider bills an MCO for the service the prior arrangement with the enrollee becomes null and void without regard to any prior arrangement worked out with the enrollee.

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  2.6.7.5.1.3   If the enrollee’s TennCare eligibility is pending at the time services are provided, however, all monies collected, except applicable TennCare cost sharing or patient liability amounts shall be refunded when a claim is submitted to an MCO because the provider agreed to accept TennCare assignment once retroactive TennCare eligibility was established. (The monies collected shall be refunded as soon as a claim is submitted and shall not be held conditionally upon payment of the claim.)
 
  2.6.7.5.1.4   If the services are not covered because they are in excess of an enrollee’s benefit limit, and the provider complies with applicable TennCare rules and regulations.
 
  2.6.7.5.2   The CONTRACTOR shall require, as a condition of payment, that the provider accept the amount paid by the CONTRACTOR or appropriate denial made by the CONTRACTOR (or, if applicable, payment by the CONTRACTOR that is supplementary to the enrollee’s third party payer) plus any applicable amount of TennCare cost sharing or patient liability responsibilities due from the enrollee as payment in full for the service. Except in the circumstances described above, if the CONTRACTOR is aware that a provider, or a collection agency acting on the provider’s behalf, bills an enrollee for amounts other than the applicable amount of TennCare cost sharing or patient liability responsibilities due from the enrollee, the CONTRACTOR shall notify the provider and demand that the provider and/or collection agency cease such action against the enrollee immediately. If a provider continues to bill an enrollee after notification by the CONTRACTOR, the CONTRACTOR shall refer the provider to the Tennessee Bureau of Investigation.
9. Section 2.7 shall be deleted in its entirety and replaced with the following:
2.7 SPECIALIZED SERVICES
2.7.1 Emergency Services
  2.7.1.1   Emergency services (as defined in Section 1 of this Agreement) shall be available twenty-four (24) hours a day, seven (7) days a week.
 
  2.7.1.2   The CONTRACTOR shall review and approve or disapprove claims for emergency services based on the definition of emergency medical condition specified in Section 1 of this Agreement. The CONTRACTOR shall base coverage decisions for emergency services on the severity of the symptoms at the time of presentation and shall cover emergency services where the presenting symptoms are of sufficient severity to constitute an emergency medical condition in the judgment of a prudent layperson. The CONTRACTOR shall not impose restrictions on coverage of emergency services more restrictive than those permitted by the prudent layperson standard.
 
  2.7.1.3   The CONTRACTOR shall provide coverage for inpatient and outpatient emergency services, furnished by a qualified provider, regardless of whether the member obtains the services from a contract provider, that are needed to evaluate or stabilize an emergency medical condition that is found to exist using the prudent layperson standard. These services shall be provided without prior authorization in accordance with 42 CFR 438.114. The CONTRACTOR shall pay for any emergency screening examination services conducted to determine whether an emergency medical

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      condition exists and for all emergency services that are medically necessary until the member is stabilized.
 
  2.7.1.4   If an emergency screening examination leads to a clinical determination by the examining provider that an actual emergency medical condition exists, the CONTRACTOR shall pay for both the services involved in the screening examination and the services required to stabilize the member. The CONTRACTOR shall be required to pay for all emergency services which are medically necessary until the clinical emergency is stabilized. This includes all medical and behavioral health services that may be necessary to assure, within reasonable medical probability, that no material deterioration of the member’s condition is likely to result from, or occur during, discharge of the member or transfer of the member to another facility. If there is a disagreement between the treating facility and the CONTRACTOR concerning whether the member is stable enough for discharge or transfer, or whether the medical benefits of an un-stabilized transfer outweigh the risks, the judgment of the attending provider(s) actually caring for the member at the treating facility prevails and is binding on the CONTRACTOR. The CONTRACTOR, however, may establish arrangements with a treating facility whereby the CONTRACTOR may send one of its own providers with appropriate emergency room privileges to assume the attending provider’s responsibilities to stabilize, treat, and transfer the member, provided that such arrangement does not delay the provision of emergency services.
 
  2.7.1.5   The CONTRACTOR shall not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard, turned out to be non-emergency in nature. If an emergency screening examination leads to a clinical determination by the examining provider that an actual emergency medical condition does not exist, then the determining factor for payment liability shall be whether the member had acute symptoms of sufficient severity at the time of presentation. In such cases, the CONTRACTOR shall review the presenting symptoms of the member and shall pay for all services involved in the screening examination where the presenting symptoms (including severe pain) were of sufficient severity to have warranted emergency attention under the prudent layperson standard regardless of final diagnosis.
 
  2.7.1.6   When the member’s PCP or the CONTRACTOR instructs the member to seek emergency services, the CONTRACTOR shall be responsible for payment for the medical screening examination and for other medically necessary emergency services, without regard to whether the member’s condition meets the prudent layperson standard.
 
  2.7.1.7   Once the member’s condition is stabilized, the CONTRACTOR may require prior authorization for hospital admission or follow-up care.
2.7.2 Behavioral Health Services
  2.7.2.1   General Provisions
 
  2.7.2.1.1   The CONTRACTOR shall provide all behavioral health services as described in this Section, Section 2.6.1 and Attachment I.

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  2.7.2.1.2   The CONTRACTOR shall provide behavioral health services in accordance with best practice guidelines, rules and regulations, and policies and procedures issued by TDMHDD and approved by the Bureau of TennCare, including but not limited to “Managed Care Standards for Delivery of Behavioral Health Services”.
 
  2.7.2.1.3   The CONTRACTOR shall ensure that all members receiving behavioral health services from providers whose primary focus is to render behavioral health services have individualized treatment plans. Providers included in this requirement are:
 
  2.7.2.1.3.1   Community mental health agencies;
 
  2.7.2.1.3.2   Case management agencies;
 
  2.7.2.1.3.3   Psychiatric rehabilitation agencies;
 
  2.7.2.1.3.4   Psychiatric and substance abuse residential treatment facilities; and
 
  2.7.2.1.3.5   Psychiatric and substance abuse inpatient facilities.
 
  2.7.2.1.4   Individualized treatment plans shall be completed within thirty (30) calendar days of the start date of service and updated every six (6) months, or more frequently as clinically appropriate. The treatment plans shall be developed, negotiated and agreed upon by the members and/or their support systems in face-to-face encounters and shall be used to identify the treatment needs necessary to meet the members’ stated goals. The duration and intensity of treatment shall promote the recovery and resilience of members and shall be documented in the treatment plans.
 
  2.7.2.2   Psychiatric Inpatient Hospital Services
 
  2.7.2.2.1   The CONTRACTOR shall ensure that all psychiatric inpatient hospitals serving children, youth, and adults separate members by age and render developmental age appropriate services.
 
  2.7.2.2.2   The CONTRACTOR shall require that all psychiatric inpatient facilities are accredited by the Joint Commission and accept voluntary and involuntary admissions.
 
  2.7.2.3   24-Hour Psychiatric Residential Treatment
 
  2.7.2.3.1   The CONTRACTOR shall ensure that 24-hour psychiatric residential treatment facilities (RTFs) serving children, youth, and adults separate members by age and render developmental age appropriate services.
 
  2.7.2.3.2   The CONTRACTOR shall ensure RTFs have the capacity to render short term crisis stabilization and long-term treatment and rehabilitation.
 
  2.7.2.3.3   The CONTRACTOR shall ensure all RTFs meet local housing codes.
 
  2.7.2.3.4   The CONTRACTOR shall ensure all RTFs are accredited by a State-recognized accreditation organization as required by 42 CFR 441.151.

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  2.7.2.4   Outpatient Mental Health Services
 
  2.7.2.4.1   The CONTRACTOR shall ensure that outpatient mental health providers (including providers of intensive outpatient and providers of partial hospitalization services) serving children, youth and adults separate members by age and render developmental age appropriate services.
 
  2.7.2.4.2   The CONTRACTOR shall ensure outpatient mental health providers are capable of rendering services both on and off site, as appropriate, depending on the services being rendered. On site services include, but are not limited to intensive outpatient services, partial hospitalization and many types of therapy. Off site services include but are not limited to intensive in home service for children and youth and home and community treatment for adults.
 
  2.7.2.5   Inpatient, Residential & Outpatient Substance Abuse Services
  2.7.2.5.1   The CONTRACTOR shall provide substance abuse treatment through inpatient, residential and outpatient services.
 
  2.7.2.5.2   Detoxification services may be rendered as part of inpatient, residential or outpatient services, as clinically appropriate. The CONTRACTOR shall ensure all member detoxifications are supervised by Tennessee licensed physicians with a minimum daily re-evaluations by a physician or a registered nurse.
 
  2.7.2.6   Mental Health Case Management
 
  2.7.2.6.1   The CONTRACTOR shall provide mental health case management services only through providers licensed by the State to provide mental health outpatient services.
 
  2.7.2.6.2   The CONTRACTOR shall provide mental health case management services according to mental health case management standards set by the State and outlined in Attachment I. Mental health case management services shall consist of two (2) levels of service as specified in Attachment I.
 
  2.7.2.6.3   The CONTRACTOR shall require its providers to collect and submit individual encounter records for each mental health case management visit, regardless of the method of payment by the CONTRACTOR. The CONTRACTOR shall identify and separately report “level 1” and “level 2” mental health case management encounters outlined in Attachment I.
 
  2.7.2.6.4   The CONTRACTOR shall require mental health case managers to involve the member, the member’s family or parent(s), or legally appointed representative, PCP, care coordinator for CHOICES members, and other agency representatives, if appropriate and authorized by the member as required, in mental health case management activities.
 
  2.7.2.6.5   The CONTRACTOR shall ensure the continuing provision of mental health case management services to members under the conditions and time frames indicated below:

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  2.7.2.6.5.1   Members receiving mental health case management services at the start date of operations shall be maintained in mental health case management until such time as the member no longer qualifies on the basis of medical necessity or refuses treatment;
 
  2.7.2.6.5.2   Members discharged from psychiatric inpatient hospitals and psychiatric residential treatment facilities shall be evaluated for mental health case management services and provided with appropriate behavioral health follow-up services; and
 
  2.7.2.6.5.3   The CONTRACTOR shall review the cases of members referred by PCPs or otherwise identified to the CONTRACTOR as potentially in need of mental health case management services and shall contact and offer such services to all members who meet medical necessity criteria.
 
  2.7.2.7   Psychiatric Rehabilitation Services
 
      The CONTRACTOR shall provide psychiatric rehabilitation services in accordance with the requirements in Attachment I. As described in Attachment I, the covered array of services available under psychiatric rehabilitation are psychosocial rehabilitation, supported employment, peer support, illness management and recovery, and supported housing. An individual may receive one or more of these services and may receive different services from different providers.
 
  2.7.2.8   Behavioral Health Crisis Services
 
  2.7.2.8.1   Entry into the Behavioral Health Crisis Services System
 
  2.7.2.8.1.1   The State shall maintain a statewide toll-free telephone number for entry into the behavioral health crisis system. This line shall be for any individual in the general population for the purposes of providing immediate phone intervention by trained crisis specialists and dispatch of mobile crisis teams.
 
  2.7.2.8.1.2   The CONTRACTOR shall ensure that the crisis telephone line is linked to an appropriate crisis service team staffed by qualified crisis service providers in order to provide crisis intervention services to members.
 
  2.7.2.8.1.3   As required in Section 2.11.5.3, the CONTRACTOR shall contract with specified crisis service teams for both adults and children as directed by the State.
 
  2.7.2.8.1.4   The CONTRACTOR shall require the crisis service teams to provide telephone and walk-in triage screening services, telephone and face-to-face crisis intervention/assessment services, and follow-up telephone or face-to-face assessments to ensure the safety of the member until the member’s treatment begins and/or the crisis is alleviated and/or stabilized.
 
  2.7.2.8.1.5   Prior to admission to a psychiatric inpatient hospital on an involuntary basis, the CONTRACTOR shall ensure that the member has been evaluated by a crisis team. In addition, the CONTRACTOR shall ensure that Tennessee’s statutory requirement for a face-to-face evaluation by a mandatory pre-screening agent (MPA), is conducted to assess eligibility for emergency involuntary admission to

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      an RMHI (Regional Mental Health Institute) and determine whether all available less drastic alternatives services and supports are unsuitable.
  2.7.2.8.2   Behavioral Health Crisis Respite and Crisis Stabilization Services
 
  2.7.2.8.2.1   The CONTRACTOR shall ensure access to behavioral health crisis respite and crisis stabilization services.
 
  2.7.2.8.2.2   Behavioral health crisis respite services provide immediate shelter to members with emotional/behavioral problems who are in need of emergency respite. The CONTRACTOR shall ensure that behavioral health crisis respite services are provided in a CONTRACTOR approved community location.
 
  2.7.2.8.2.3   The CONTRACTOR shall ensure behavioral health crisis stabilization services are rendered at sites licensed by the State. These services are more intensive than regular behavioral health crisis services in that they require more secure environments, highly trained staff, and typically have longer stays.
 
  2.7.2.8.3   The CONTRACTOR shall monitor behavioral health crisis services and report information to TENNCARE on a quarterly basis as described in Section 2.30.4.4.
 
  2.7.2.9   Clinically Related Group (CRG) and Target Population Group (TPG) Assessments
 
  2.7.2.9.1   The CONTRACTOR shall provide CRG/TPG assessments in response to requests from members or legally appointed representatives or, in the case of minors, the members’ parents or legally appointed representatives, behavioral health providers, PCPs, or the State.
 
  2.7.2.9.2   The CONTRACTOR shall complete CRG/TPG assessments within fourteen (14) calendar days of the requests. The CONTRACTOR shall not require prior authorization in order for a member to receive a CRG/TPG assessment.
 
  2.7.2.9.3   The CONTRACTOR shall ensure that its contract providers are trained and that there is sufficient capacity to perform CRG/TPG assessments. The CONTRACTOR shall require providers to use the CRG/TPG assessment form(s) as appropriate, prescribed by and in accordance with the policies of the state. The CRG/TPG assessments shall be subject to review and prior written approval by the State.
 
  2.7.2.9.4   The CONTRACTOR shall identify persons in need of CRG/TPG assessments. The CONTRACTOR shall use the CRG/TPG assessments to identify persons who are SPMI or SED for reporting and tracking purposes, in accordance with the definitions contained in Section 1.
 
  2.7.2.9.5   The CONTRACTOR shall ensure that providers who perform CRG/TPG assessments have been trained and authorized by the State to perform CRG/TPG assessments. Certified trainers shall be responsible for providing rater training within their agencies.
 
  2.7.2.9.6   The CONTRACTOR shall reject all CRG/TPG assessments completed by unapproved raters. The CONTRACTOR shall report on rejected assessments as required in Section 2.30.4.6.

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  2.7.2.9.7   The CONTRACTOR shall conduct audits of CRG/TPG assessments for accuracy and conformity to state policies and procedures. The CONTRACTOR shall audit all providers conducting these assessments on at least an annual basis. The methodology for these audits and the results of these audits shall be reported as required in Sections 2.30.4.7 and 2.30.4.8.
 
  2.7.2.10   Judicial Services
 
  2.7.2.10.1   The CONTRACTOR shall provide covered court ordered behavioral health services to its members pursuant to court order(s). The CONTRACTOR shall furnish these services in the same manner as services furnished to other members.
 
  2.7.2.10.2   The CONTRACTOR shall provide for behavioral health services to its members in accordance with state law. Specific laws employed include the following:
 
  2.7.2.10.2.1   Psychiatric treatment for persons found by the court to require judicial psychiatric hospitalization (TCA 33-6 part 4 and part 5). The CONTRACTOR may apply medical necessity criteria to the situation after seventy-two (72) hours of emergency services, unless there is a court order prohibiting release;
 
  2.7.2.10.2.2   Judicial review of discharge for persons hospitalized by a circuit, criminal or juvenile court (TCA 33-6-708);
 
  2.7.2.10.2.3   Access to and provision of mandatory outpatient psychiatric treatment and services to persons who are discharged from psychiatric hospitals after being hospitalized (TCA 33-6, Part 6);
 
  2.7.2.10.2.4   Inpatient psychiatric examination for up to forty-eight (48) hours for persons whom the court has ordered to be detained for examination but who have been unwilling to be evaluated for hospital admission (TCA 33-3-607);
 
  2.7.2.10.2.5   Voluntary psychiatric hospitalization for persons when determined to be medically necessary, subject to the availability of suitable accommodations (TCA 33-6, Part 2); and
 
  2.7.2.10.2.6   Voluntary psychiatric hospitalization for persons with a severe impairment when determined to be medically necessary but who do not meet the criteria for emergency involuntary hospitalization, subject to the availability of suitable accommodations (TCA 33-6, Part 3).
 
  2.7.2.11   Mandatory Outpatient Treatment
 
  2.7.2.11.1   The CONTRACTOR shall provide mandatory outpatient treatment for individuals found not guilty by reason of insanity following a thirty (30) to sixty (60) calendar day inpatient evaluation. Treatment can be terminated only by the court pursuant to TCA 33-7-303(b).
 
  2.7.2.11.2   The State will assume responsibility for all forensic services other than the mandatory outpatient treatment service identified in Section 2.7.2.11.1 (TCA 33-7- 30 1(a), 33-7-301(b), 33-7-303(a) and 33-7-303(c)).

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2.7.3 Self-Direction of Health Care Tasks
The CONTRACTOR shall, as specified in TennCare rules and regulations, offer CHOICES members the option to direct and supervise a paid personal aide in the performance of health care tasks.
2.7.4 Health Education and Outreach
  2.7.4.1   The CONTRACTOR shall develop programs and participate in activities to enhance the general health and well-being of members. Health education and outreach programs and activities may include the following:
 
  2.7.4.1.1   General physical, behavioral health and long-term care education classes;
 
  2.7.4.1.2   Mental illness awareness programs and education campaigns with special emphasis on events such as National Mental Health Month and National Depression Screening Day;
 
  2.7.4.1.3   Smoking cessation programs with targeted outreach for adolescents and pregnant women;
 
  2.7.4.1.4   Nutrition counseling;
 
  2.7.4.1.5   Early intervention and risk reduction strategies to avoid complications of disability and chronic illness;
 
  2.7.4.1.6   Prevention and treatment of substance abuse;
 
  2.7.4.1.7   Self care training, including self-examination;
 
  2.7.4.1.8   Need for clear understanding of how to take medications and the importance of coordinating all medications;
 
  2.7.4.1.9   Understanding the difference between emergent, urgent and routine health conditions;
 
  2.7.4.1.10   Education for members on the significance of their role in their overall health and welfare and available resources;
 
  2.7.4.1.11   Education for caregivers on the significance of their role in the overall health and welfare of the member and available resources;
 
  2.7.4.1.12   Education for members and caregivers about identification and reporting of suspected abuse and neglect;
 
  2.7.4.1.13   Telephone calls, mailings and home visits to current members for the sole purpose of educating current members about services offered by or available through the CONTRACTOR’s MCO; and

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  2.7.4.1.14   General activities that benefit the entire community (e.g., health fairs and school activity sponsorships).
 
  2.7.4.2   The CONTRACTOR shall ensure that all health education and outreach activities are prior approved in writing by TENNCARE (see Section 2.17.1).
2.7.5 Preventive Services
  2.7.5.1   The CONTRACTOR shall provide preventive services which include, but are not limited to, initial and periodic evaluations, family planning services, prenatal care, laboratory services and immunizations in accordance with TennCare rules and regulations. These services shall be exempt from TennCare cost sharing responsibilities described in Section 2.6.7 of this Agreement (see TennCare rules and regulations for service codes).
 
  2.7.5.2   Prenatal Care
 
  2.7.5.2.1   The CONTRACTOR shall provide or arrange for the provision of medically necessary prenatal care to members beginning on the date of their enrollment in the CONTRACTOR’s MCO. This requirement includes pregnant women who are presumptively eligible for TennCare, enrollees who become pregnant, as well as enrollees who are pregnant on the effective date of enrollment in the CONTRACTOR’s MCO. The requirement to provide or arrange for the provision of medically necessary prenatal care shall include assistance in making a timely appointment for a woman who is presumptively eligible and shall be provided as soon as the CONTRACTOR becomes aware of the enrollment. For a woman in her second or third trimester, the appointment shall occur as required in Section 2.11.4.2. In the event a member enrolling in the CONTRACTOR’s MCO is receiving medically necessary prenatal care services the day before enrollment, the CONTRACTOR shall comply with the requirements in Sections 2.9.2.2 and 2.9.2.3 regarding prior authorization of prenatal care.
 
  2.7.5.2.2   Failure of the CONTRACTOR to respond to a member’s request for prenatal care by failing to identify a prenatal care provider to honor a request from a member, including a presumptively eligible member, (or from an PCP or patient advocate acting on behalf of a member) for a prenatal care appointment shall be considered a material breach of this Agreement.
 
  2.7.5.2.3   The CONTRACTOR shall notify all contract providers that any unreasonable delay in providing care to a pregnant member seeking prenatal care shall be considered a material breach of the provider’s agreement with the CONTRACTOR. Unreasonable delay in care for pregnant members shall mean failure of the prenatal care provider to meet the accessibility requirements required in Section 2.11.4 of this Agreement.
2.7.6 TENNderCare
  2.7.6.1   General Provisions
 
  2.7.6.1.1   The CONTRACTOR shall provide TENNderCare services to members under age twenty-one (21) in accordance with TennCare and federal requirements including TennCare rules and regulations, TennCare policies and procedures, 42 USC

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      1396a(a)(43), 1396d(a) and (r), 42 CFR Part 441, Subpart B, the Omnibus Budget Reconciliation Act of 1989, and the State Medicaid Manual. TENNderCare services means early and periodic screening, diagnosis and treatment of members under age twenty-one (21) to ascertain children’s individual (or individualized/or on an individual basis) physical and mental defects, and providing treatment to correct or ameliorate, or prevent from worsening defects and physical and mental illnesses and conditions discovered by the screening services, regardless of whether the required service is a covered benefit as described in Section 2.6.1.
 
  2.7.6.1.2   The CONTRACTOR shall use the name “TENNderCare” in describing or naming the State’s EPSDT program or services. This requirement is applicable for all policies, procedures and other material, regardless of the format or media. No other names or labels shall be used.
 
  2.7.6.1.3   The CONTRACTOR shall have written policies and procedures for the TENNderCare program that include coordinating services with child-serving agencies and providers, providing all medically necessary TENNderCare services to all eligible members under the age of twenty-one (21) regardless of whether the service is included in the Medicaid State Plan, and conducting outreach and education. The CONTRACTOR shall ensure the availability and accessibility of required health care resources and shall help members and their parents or legally appointed representatives use these resources effectively.
 
  2.7.6.1.4   The CONTRACTOR shall be responsible for and comply with all provisions related to screening, vision, dental, and hearing services (including making arrangements for necessary follow-up if all components of a screen cannot be completed in a single visit).
 
  2.7.6.1.5   The CONTRACTOR shall:
 
  2.7.6.1.5.1   Require that providers provide TENNderCare services;
 
  2.7.6.1.5.2   Require that providers make appropriate referrals and document said referrals in the member’s medical record;
 
  2.7.6.1.5.3   Educate contract providers about proper coding and encourage them to submit the appropriate diagnosis codes identified by TENNCARE in conjunction with evaluation and management procedure codes for TENNderCare services;
 
  2.7.6.1.5.4   Educate contract providers about how to submit claims with appropriate codes and modifiers as described in standardized billing requirements (e.g., CPT, HCPCS, etc.) and require that they adjust billing methodology according to described components of said procedure codes/modifiers; and
 
  2.7.6.1.5.5   Monitor provider compliance with required TENNderCare activities including compliance with proper coding.
 
  2.7.6.1.6   The CONTRACTOR shall require that its contract providers notify the CONTRACTOR in the event a screening reveals the need for other health care services and the provider is unable to make an appropriate referral for those services. Upon notification of the inability to make an appropriate referral, the

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      CONTRACTOR shall secure an appropriate referral and contact the member to offer scheduling assistance and transportation for members lacking access to transportation. In the event the failed referral is for dental services, the CONTRACTOR shall coordinate with the DBM to arrange for services.
 
  2.7.6.1.7   The CONTRACTOR shall not require prior authorization for periodic and interperiodic screens conducted by PCPs. The CONTRACTOR shall provide all medically necessary covered services regardless of whether the need for such services was identified by a provider who had received prior authorization from the CONTRACTOR or from a contract provider.
 
  2.7.6.1.8   The CONTRACTOR shall have a tracking system to monitor each TENNderCare eligible member’s receipt of the required screening, diagnosis, and treatment services. The tracking system shall have the ability to generate immediate reports on each member’s TENNderCare status, reflecting all encounters reported more than sixty (60) days prior to the date of the report.
 
  2.7.6.1.9   In the event that a member under sixteen (16) years of age is seeking behavioral health TENNderCare services and the member’s parent(s), or legally appointed representative is unable to accompany the member to the examination, the CONTRACTOR shall require that its providers either contact the member’s parent(s), or legally appointed representative to discuss the findings and inform the family of any other necessary health care, diagnostic services, treatment or other measures recommended for the member or notify the MCO to contact the parent(s), or legally appointed representative with the results.
 
  2.7.6.2   Member Education and Outreach
 
  2.7.6.2.1   The CONTRACTOR shall be responsible for outreach activities and for informing members who are under the age of twenty-one (21), or their parent or legally appointed representative, of the availability of TENNderCare services. All TENNderCare member materials shall be submitted to TENNCARE for written approval prior to distribution in accordance with Section 2.17.1 and shall be made available in accordance with the requirements specified in Section 2.17.2.
 
  2.7.6.2.2   The CONTRACTOR shall have a minimum of six (6) “outreach contacts” per member per calendar year in which it provides information about TENNderCare to members. The minimum “outreach contacts” include: one (1) member handbook as described in Section 2.17.4, four (4) quarterly member newsletters as described in Section 2.17.5, and one (1) reminder notice issued before a screening is due. The reminder notice shall include an offer of transportation and scheduling assistance.
 
  2.7.6.2.2.1   If the CONTRACTOR’s TENNderCare screening rate is below ninety percent (90%), as determined in the most recent CMS 416 report, the CONTRACTOR shall conduct New Member Calls for all new members under the age of twenty- one (21) to inform them of TENNderCare services including assistance with appointment scheduling and transportation to appointments.
 
  2.7.6.2.2.2   The CONTRACTOR shall have the ability to conduct EPSDT outreach in formats appropriate to members who are blind, deaf, illiterate or have Limited English Proficiency. At least one of the 6 outreach attempts identified above shall

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      advise members regarding how to request and/or access such assistance and/or information. The CONTRACTOR shall collaborate with agencies that have established procedures for working with special populations in order to develop effective outreach materials.
 
  2.7.6.2.3   The CONTRACTOR shall have a mechanism for systematically notifying families when TENNderCare screens are due.
 
  2.7.6.2.4   As part of its TENNderCare policies and procedures, the CONTRACTOR shall have a written process for following up with members who do not get their screenings timely. This process for follow up shall include provisions for documenting all outreach attempts and maintaining records of efforts made to reach out to members who have missed screening appointments or who have failed to receive regular check-ups. The CONTRACTOR shall make at least one (1) effort per quarter in excess of the six (6) “outreach contacts” to get the member in for a screening. The efforts, whether written or oral, shall be different each quarter. The CONTRACTOR is prohibited from simply sending the same letter four (4) times.
 
  2.7.6.2.5   The CONTRACTOR shall have a process for determining if a member who is eligible for TENNderCare has used no services within a year and shall make two (2) reasonable attempts to re-notify such members about TENNderCare. The attempts must be different in format or message. One (1) of these attempts can be a referral to DOH for a screen. (These two (2) attempts are in addition to the one (1) attempt per quarter mentioned in Section 2.7.6.2.4 above.)
 
  2.7.6.2.6   The CONTRACTOR shall require that providers have a process for documenting services declined by a parent or legally appointed representative or mature competent child, specifying the particular service was declined. This process shall meet all requirements outlined in Section 5320.2.A of the State Medicaid Manual.
 
  2.7.6.2.7   The CONTRACTOR shall make and document a minimum of two (2) reasonable attempts to find a member with one (1) of the two (2) attempts being made within thirty (30) days of receipt of mail returned as undeliverable and the second being made within ninety (90) days of receipt of mail returned as undeliverable. At least one (1) of these attempts shall be by phone.
 
  2.7.6.2.8   The CONTRACTOR shall make available to members and families accurate lists of names and phone numbers of contract providers who are currently accepting TennCare members as described in Section 2.17.8 of this Agreement.
 
  2.7.6.2.9   The CONTRACTOR shall target specific informing activities to pregnant women and families with newborns. Provided that the CONTRACTOR is aware of the pregnancy, the CONTRACTOR shall inform all pregnant women prior to the estimated delivery date about the availability of TENNderCare services for their children. The CONTRACTOR shall offer TENNderCare services for the child when it is born.
 
  2.7.6.2.10   The CONTRACTOR shall provide member education and outreach in community settings. Outreach events shall be conducted in the Grand Region covered by this Agreement in accordance with the following specifications:

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  2.7.6.2.10.1   Outreach events shall number a minimum of one hundred fifty (150) per year with no less than twenty-five (25) per region, per quarter.
 
  2.7.6.2.10.1.1   At least thirty percent (30%) shall be conducted in rural areas. Results of the CONTRACTOR’s 416 report and HEDIS report, as well as county demographics, shall be utilized in determining counties for targeted activities and in developing strategies for specific populations.
 
  2.7.6.2.10.2   The CONTRACTOR shall contact a minimum of twenty-five (25) state agencies or community-based organizations per quarter, to either educate them on services available through the CONTRACTOR or to develop outreach and educational initiatives. All of the agencies engaged shall be those who serve TennCare enrollees. Collaborative activities should include those designed to reach enrollees with limited English proficiency, low literacy levels, behavioral health and special health care needs or who are pregnant.
 
  2.7.6.3   Screening
 
  2.7.6.3.1   The CONTRACTOR shall provide periodic comprehensive child health assessments meaning, “regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth.”
 
  2.7.6.3.2   At a minimum, these screens shall include periodic and interperiodic screens and be provided at intervals which meet reasonable standards of medical, behavioral and dental practice, as determined by the State after consultation with recognized medical and dental organizations involved in child health care. The State has determined that “reasonable standards of medical and dental practice” are those standards set forth in the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care for medical practice and American Academy of Pediatric Dentistry (AAPD) guidelines for dental practice. Tools used for screening shall be consistent with the screening guidelines recommended by the State which are available on the TennCare web site. These include, but are not limited to recommended screening guidelines for developmental/behavioral surveillance and screening, hearing screenings, and vision screenings.
 
  2.7.6.3.3   The screens shall include, but not be limited to:
 
  2.7.6.3.3.1   Comprehensive health and developmental history (including assessment of physical and mental health development and dietary practices);
 
  2.7.6.3.3.2   Comprehensive unclothed physical examination, including measurements (the child’s growth shall be compared against that considered normal for the child’s age and gender);
 
  2.7.6.3.3.3   Appropriate immunizations scheduled according to the most current Advisory Committee on Immunization Practices (ACIP) schedule according to age and health history;

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  2.7.6.3.3.4   Appropriate vision and hearing testing provided at intervals which meet reasonable standards of medical practice and at other intervals as medically necessary to determine the existence of suspected illness or condition;
 
  2.7.6.3.3.5   Appropriate laboratory tests (including lead toxicity screening appropriate for age and risk factors). All children are considered at risk and shall be screened for lead poisoning. All children shall receive a screening blood lead test at twelve (12) and twenty-four (24) months of age. Children between the ages of thirty-six (36) months and seventy-two (72) months of age shall receive a screening blood lead test if they have not been previously screened for lead poisoning. A blood lead test shall be used when screening Medicaid-eligible children. A blood lead test equal to or greater than ten (10) ug/dL obtained by capillary specimen (finger stick) shall be confirmed by using a venous blood sample; and
 
  2.7.6.3.3.6   Health education which includes anticipatory guidance based on the findings of all screening. Health education should include counseling to both members and members’ parents or to the legally appointed representative to assist in understanding what to expect in terms of the child’s development and to provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention.
 
  2.7.6.3.4   The CONTRACTOR shall encourage providers to refer children to dentists for periodic dental screens beginning no later than three (3) years of age and earlier as needed (as early as six (6) to twelve (12) months in accordance with the American Academy of Pediatric Dentistry (AAPD) guidelines) and as otherwise appropriate.
 
  2.7.6.3.5   The CONTRACTOR shall establish a procedure for PCPs or other providers completing TENNderCare screenings to refer TENNderCare eligible members requiring behavioral health services to appropriate providers.
 
  2.7.6.4   Services
 
  2.7.6.4.1   Should screenings indicate a need, the CONTRACTOR shall provide all necessary health care, diagnostic services, treatment, and other measures described in 42 USC 1396d(a) (Section 1905(a) of the Social Security Act) to correct or ameliorate or prevent from worsening defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan (see Section 2.7.6.4.8). This includes, but is not limited to, the services detailed below.
 
  2.7.6.4.2   The CONTRACTOR shall provide treatment for defects in vision and hearing, including eyeglasses and hearing aids.
 
  2.7.6.4.3   The CONTRACTOR shall coordinate with the DBM to ensure that TENNderCare eligible members receive dental care services furnished by direct referral to a dentist, at as early an age as necessary, and at intervals which meet reasonable standards of dental practice as determined by the State and at other intervals as medically necessary to determine the existence of a suspected illness or condition.
 
  2.7.6.4.4   The CONTRACTOR shall not require prior authorization or written PCP referral in order for a member to obtain a mental health or substance abuse assessment, whether

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      the assessment is requested as follow-up to a TENNderCare screening or an interperiodic screening. This requirement shall not preclude the CONTRACTOR from requiring notification for a referral for an assessment. Furthermore, the CONTRACTOR shall establish a procedure for PCPs, or other providers, completing TENNderCare screenings, to refer members under the age of twenty-one (21) for a mental health or substance abuse assessment.
 
  2.7.6.4.5   For services not covered by Section 1905(a) of the Social Security Act, but found to be needed as a result of conditions disclosed during screening and diagnosis, the CONTRACTOR shall provide referral assistance as required by 42 CFR 441.61, including referral to providers and State health agencies.
 
  2.7.6.4.6   Transportation Services
 
  2.7.6.4.6.1   The CONTRACTOR shall provide transportation assistance for a child and for the child’s escort or accompanying adult, including related travel expenses, cost of meals, and lodging en route to and from TennCare covered services. The requirement to provide the cost of meals shall not be interpreted to mean that a member (or the child’s escort or accompanying adult) can request meals while in transport to and from care. Reimbursement for meals and lodging shall only be provided when transportation for a TennCare covered service cannot be completed in one (1) day and would require an overnight stay.
 
  2.7.6.4.6.2   The CONTRACTOR shall offer transportation and scheduling assistance to all members under age twenty-one (21) who do not have access to transportation in order to access covered services. This may be accomplished through various means of communication to members, including but not limited to, member handbooks, TENNderCare outreach notifications, etc.
 
  2.7.6.4.7   Services for Elevated Blood Lead Levels
 
  2.7.6.4.7.1   The CONTRACTOR shall provide follow up for elevated blood lead levels in accordance with the State Medicaid Manual, Part 5. The Manual currently says that children with blood lead levels equal to or greater than ten (10) ug/dL should be followed according to CDC guidelines. These guidelines include follow up blood tests and investigations to determine the source of lead, when indicated.
 
  2.7.6.4.7.2   The CONTRACTOR shall provide for any follow up service within the scope of the federal Medicaid statute, including diagnostic or treatment services determined to be medically necessary when elevated blood lead levels are identified in children. Such services would include both MCO case management services and a one (1) time investigation to determine the source of lead.
 
  2.7.6.4.7.3   The CONTRACTOR is responsible for the primary environmental lead investigation—commonly called a “lead inspection”—for children when elevated blood levels suggest a need for such an investigation.
 
  2.7.6.4.7.4   If the lead inspection does not reveal the presence of lead paint in the home, there may be a need for other testing, such as risk assessments involving water and soil sampling or inspections of sites other than the primary residence if the child spends a substantial amount of time in another location. The

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      CONTRACTOR is not responsible for either the risk assessments or the lead inspection at the secondary site. However, the CONTRACTOR shall contact the DOH when these services are indicated as this agency is responsible for these services.
 
  2.7.6.4.7.5   CONTRACTOR reimbursement for the primary environmental investigations is limited to the items specified in Part 5 of the State Medicaid Manual. These items include the health professional’s time and activities during the on-site investigation of the child’s primary residence. They do not include testing of environmental substances such as water, paint, or soil.
 
  2.7.6.4.8   Services Chart
 
      Pursuant to federal and state requirements, TennCare enrollees under the age of 21 are eligible for all services listed in Section 1905(a) of the Social Security Act. These services, and the entity responsible for providing them to TennCare enrollees under the age of 21, are listed below. Notwithstanding any other provision of this Agreement, the CONTRACTOR shall provide all services for which “MCO” is identified as the responsible entity to members under the age of 21. All services, other than TENNderCare screens and interperiodic screens, must be medically necessary in order to be covered by the CONTRACTOR. The CONTRACTOR shall provide all medically necessary TENNderCare covered services regardless of whether or not the need for such services was identified by a provider whose services had received prior authorization from the CONTRACTOR or by a contract provider.
         
Services Listed in Social        
Security Act Section   Responsible Entity in    
1905(a)   Tennessee   Comments
(1)        Inpatient hospital
services (other than services in an institution for mental diseases)
  MCO    
 
       
(2)(A)   Outpatient hospital services
  MCO    
 
       
(2)(B)   Rural health clinic services (RHCs)
  MCO   MCOs are not required to contract with RHCs if the services are available through other contract providers.
 
       
(2)(C)   Federally-qualified health center services (FQHCs)
  MCO   MCOs are not required to contract with FQHCs if they can demonstrate adequate provider capacity without them.
 
       
(3)         Other laboratory and X-ray services
  MCO    
 
       
(4)(A)   Nursing facility services for individuals age 21 and older
      Not applicable for
TENNderCare

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Services Listed in Social        
Security Act Section   Responsible Entity in    
1905(a)   Tennessee   Comments
(4)(B)   EPSDT services
  MCO for physical health and behavioral health services; DBM for dental services except as described in Section 2.6.1.3;
PBM for pharmacy services as described except as in Section 2.6.1.3
   
 
       
(4)(C)   Family planning services and supplies
  MCO;
PBM for pharmacy services except as described in Section 2.6.1.3
   
 
       
(5)(A)   Physicians’ services furnished by a physician, whether furnished in the office, the patient’s home, a hospital, or a nursing facility
  MCO    
 
       
(5)(B)   Medical and surgical services furnished by a dentist
  DBM except as described in Section 2.6.1.3    
 
       
(6)        Medical care, or any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law
  MCO   See Item (13)
 
       
(7)        Home health care
services
  MCO    
 
       
(8)        Private duty nursing
services
  MCO    
 
       
(9)        Clinic services
  MCO    
 
       
(10)      Dental services
  DBM except as described in Section 2.6.1.3    
 
       
(11)      Physical therapy and related services
  MCO    
 
       
(12)      Prescribed drugs, dentures, and prosthetic devices, and eyeglasses
  MCO;
PBM for pharmacy services except as described in Section 2.6.1.3;
DBM for dentures
   
 
       
(13)     Other diagnostic, screening, preventive, and rehabilitative
  MCO for physical health and behavioral health services;
DBM for dental services
  The following are considered practitioners of the healing arts in

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Services Listed in Social        
Security Act Section   Responsible Entity in    
1905(a)   Tennessee   Comments
services, including any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under state law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level
  except as described in Section 2.6.1.3;
PBM for pharmacy services except as described in Section 2.6.1.3
  Tennessee law:1
      Alcohol and drug abuse counselor
      Athletic trainer
      Audiologist
      Certified acupuncturist
      Certified master social worker
      Certified nurse practitioner
      Certified professional counselor
      Certified psychological assistant
 
     
      Chiropractic physician
 
     
      Chiropractic therapy assistant
 
     
      Clinical pastoral therapist
 
     
      Dentist
 
     
      Dental assistant
 
     
      Dental hygienist
 
     
      Dietitian/nutritionist
 
     
      Dispensing optician
 
     
      Electrologist
 
     
      Emergency medical personnel
 
     
      First responder
 
     
      Hearing instrument specialist
 
     
      Laboratory personnel
 
     
      Licensed clinical perfusionist
 
     
      Licensed clinical social worker
 
     
      Licensed practical nurse
 
     
      Licensed professional
 
1   This list was provided by the Tennesse Department of Health.

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Services Listed in Social        
Security Act Section   Responsible Entity in    
1905(a)   Tennessee   Comments
 
     
      counselor
      Marital and family therapist, certified
 
     
      Marital and family therapist, licensed
 
     
      Massage therapist
 
     
      Medical doctor
 
     
      Medical doctor (special training)
 
     
      Midwives and nurse midwives
 
     
      Nurse aide
 
     
      Occupational therapist
 
     
      Occupational therapy assistant
 
     
      Optometrist
 
     
      Osteopathic physician
 
     
      Pharmacist
 
     
      Physical therapist
 
     
      Physical therapist assistant
 
     
      Physician assistant
 
     
      Podiatrist
 
     
      Psychological examiner
 
     
      Psychologist
 
     
      Registered nurse
 
     
      Registered certified reflexologist
 
     
      Respiratory care assistant
 
     
      Respiratory care technician
 
     
      Respiratory care therapist
 
       
 
     
      Senior psychological examiner
 
     
      Speech pathologist
 
     
      Speech pathology aide
 
     
      X-ray op in chiropractic physician’s office

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Services Listed in Social        
Security Act Section   Responsible Entity in    
1905(a)   Tennessee   Comments
 
     
      X-ray op in MD office
 
     
      X-ray op in osteopathic office
 
     
      X-ray op in podiatrist’s office
 
       
(14)      Inpatient hospital services and nursing facility services for individuals 65 years of age or over in an institution for mental diseases
      Not applicable for
TENNderCare
 
       
(15)      Services in an
intermediate care facility
for the mentally retarded
  TENNCARE    
 
       
(16)      Inpatient psychiatric
services for individuals
under age 21
  MCO    
 
       
(17)       Services furnished by a
nurse-midwife
  MCO   The MCOs are not required to contract with nurse-midwives if the services are available through other contract providers.
 
       
(18)      Hospice care
  MCO    
 
       
(19)      Case management services
  MCO    
 
       
(20)      Respiratory care services
  MCO    
 
       
(21)      Services furnished by a
certified pediatric nurse
practitioner or certified
family nurse practitioner
  MCO   The MCOs are not required to contract with PNPs or CFNPs if the services are available through other contract providers.
 
       
(22)      Home and community care for functionally disabled elderly individuals
      Not applicable for
TENNderCare
 
       
(23)      Community supported
living arrangements services
      Not applicable for
TENNderCare
 
       
(24)      Personal care services
  MCO    

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Services Listed in Social        
Security Act Section   Responsible Entity in    
1905(a)   Tennessee   Comments
(25)      Primary care case management services
      Not applicable
 
       
(26)      Services furnished under a PACE program
      Not applicable for
TENNderCare
 
       
(27)      Any other medical care, and any other type of remedial care recognized under state law.
  MCO for physical and behavioral health services; DBM for dental services except as described in Section 2.6.1.3;
PBM for pharmacy services except as described in Section 2.6.1.3
  See Item (13)
  2.7.6.4.8.1   Note 1: “Targeted case management services,” which are listed under Section 191 5(g)(1), are not TENNderCare services except to the extent that the definition in Section 1915(g)(2) is used with Item (19) above.
 
  2.7.6.4.8.2   Note 2: “Psychiatric residential treatment facility” is not listed in Social Security Act Section 1905(a). It is, however, defined in 42 CFR 483.352 as “a facility other than a hospital, that provides psychiatric services, as described in subpart D of part 441 of this chapter, to individuals under age twenty-one (21), in an inpatient setting.”
 
  2.7.6.4.8.3   Note 3: “Rehabilitative” services are differentiated from “habilitative” services in federal law. “Rehabilitative” services, which are TENNderCare services, are defined in 42 CFR 440.130(d) as services designed “for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level.” “Habilitative” services, which are not TENNderCare services, are defined in Section 1915(c)(5) as services designed “to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community based settings.”
 
  2.7.6.4.8.4   Note 4: Certain services are covered under a Home and Community Based waiver but are not TENNderCare services because they are not listed in the Social Security Act Section 1905(a). These services include habilitation, prevocational, supported employment services, homemaker services and respite services. (See Section 1915(c)(4).)
 
  2.7.6.4.8.5   Note 5: Certain services are not coverable even under a Home and Community Based waiver and are not TENNderCare services. These services include room and board, and special education and related services which are otherwise available through a Local Education Agency. (See Section 191 5(c)(5).)

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  2.7.6.5   Children with Special Health Care Needs
 
      Children with special health care needs are those children who are in the custody of DCS. As provided in Section 2.4.4.4, TennCare enrollees who are in the custody of DCS will be enrolled in TennCare Select.
2.7.7 Advance Directives
  2.7.7.1   The CONTRACTOR shall maintain written policies and procedures for advance directives that comply with all federal and state requirements concerning advance directives, including but not limited to 42 CFR 422.128, 438.6 and 489 Subpart I; TCA 32-11-101 et seq., 34-6-201 et seq., and 68-11-201 through 68-11-224; and any requirements as stipulated by the member. Any written information provided by the CONTRACTOR shall reflect changes in state law by the effective date specified in the law, if not specified then within thirty (30) calendar days after the effective date of the change.
 
  2.7.7.2   The CONTRACTOR shall provide its policies and procedures to all members eighteen (18) years of age and older and shall educate members about their ability to direct their care using this mechanism and shall specifically designate which staff members and/or contract providers are responsible for providing this education.
 
  2.7.7.3   The CONTRACTOR shall educate its staff about its policies and procedures on advance directives, situations in which advance directives may be of benefit to members, and their responsibility to educate members about this tool and assist them to make use of it.
 
  2.7.7.4   The CONTRACTOR, for behavioral health services, shall provide its policies and procedures to all members sixteen (16) years of age and older and shall educate members about their ability to direct their care using advance directives including the use of Declarations for Mental Health Treatment under TCA Title 33, Chapter 6, Part 10. The CONTRACTOR shall specifically designate staff members and/or providers responsible for providing this education.
 
  2.7.7.5   For CHOICES members, the care coordinator shall educate members about their ability to use advance directives during the face-to-face intake visit for current members or the face-to-face visit with new members, as applicable.
2.7.8 Sterilizations, Hysterectomies and Abortions
  2.7.8.1   The CONTRACTOR shall cover sterilizations, hysterectomies and abortions pursuant to applicable federal and state law. The CONTRACTOR shall ensure that when coverage requires the completion of a specific form, the form is properly completed as described in the instructions with the original form maintained in the member’s medical records and a copy submitted to the CONTRACTOR for retention in the event of audit.

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  2.7.8.2   Sterilizations
 
      Sterilization shall mean any medical procedure, treatment or operation done for the purpose of rendering an individual permanently incapable of reproducing. The CONTRACTOR shall cover sterilizations only if the following requirements are met:
 
  2.7.8.2.1   At least thirty (30) calendar days, but not more than one hundred eighty (180) calendar days, have passed between the date of informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery. A member may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery if at least seventy-two (72) hours have passed since the member gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least thirty (30) calendar days before the expected date of delivery;
 
  2.7.8.2.2   The member is at least twenty-one (21) years old at the time consent is obtained;
 
  2.7.8.2.3   The member is mentally competent;
 
  2.7.8.2.4   The member is not institutionalized (i.e., not involuntarily confined or detained under a civil or criminal status in a correctional or rehabilitative facility or confined in a mental hospital or other facility for the care and treatment of mental illness, whether voluntarily or involuntarily committed); and
 
  2.7.8.2.5   The member has voluntarily given informed consent on the approved “STERILIZATION CONSENT FORM” which is available on TENNCARE’s web site. The form shall be available in English and Spanish, and the CONTRACTOR shall provide assistance in completing the form when an alternative form of communication is necessary.
 
  2.7.8.3   Hysterectomies
 
  2.7.8.3.1   Hysterectomy shall mean a medical procedure or operation for the purpose of removing the uterus. The CONTRACTOR shall cover hysterectomies only if the following requirements are met:
 
  2.7.8.3.1.1   The hysterectomy is medically necessary;
 
  2.7.8.3.1.2   The member or her authorized representative, if any, has been informed orally and in writing that the hysterectomy will render the member permanently incapable of reproducing; and
 
  2.7.8.3.1.3   The member or her authorized representative, if any, has signed and dated an “ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION” form which is available on the Bureau of TennCare’s web site, prior to the hysterectomy. Informed consent shall be obtained regardless of diagnosis or age in accordance with federal requirements. The form shall be available in English and Spanish, and assistance shall be provided in completing the form when an alternative form of communication is necessary. Refer to “ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION” form and instructions for additional guidance and exceptions.

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  2.7.8.3.2   The CONTRACTOR shall not cover hysterectomies under the following circumstances:
 
  2.7.8.3.2.1   If it is performed solely for the purpose of rendering an individual permanently incapable of reproducing;
 
  2.7.8.3.2.2   If there is more than one purpose for performing the hysterectomy, but the primary purpose is to render the individual permanently incapable of reproducing; or
 
  2.7.8.3.2.3   It is performed for the purpose of cancer prophylaxis.
 
  2.7.8.4   Abortions
 
  2.7.8.4.1   The CONTRACTOR shall cover abortions and services associated with the abortion procedure only if the pregnancy is the result of an act of rape or incest; or in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.
 
  2.7.8.4.2   The CONTRACTOR shall ensure that a “CERTIFICATION OF MEDICAL NECESSITY FOR ABORTION” form, which is available on TENNCARE’s web site, is completed. The form shall be available in English and Spanish, and assistance shall be provided in completing the form when an alternative form of communication is necessary.
10. Section 2.8 shall be deleted in its entirety and replaced with the following:
2.8 DISEASE MANAGEMENT
2.8.1 General
  2.8.1.1   The CONTRACTOR shall establish and operate a disease management (DM) program for each of the following conditions:
 
  2.8.1.1.1   Maternity care management, in particular high-risk obstetrics;
 
  2.8.1.1.2   Diabetes;
 
  2.8.1.1.3   Congestive heart failure;
 
  2.8.1.1.4   Asthma;
 
  2.8.1.1.5   Coronary artery disease;
 
  2.8.1.1.6   Chronic-obstructive pulmonary disease;
 
  2.8.1.1.7   Bipolar disorder;

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  2.8.1.1.8   Major depression; and
 
  2.8.1.1.9   Schizophrenia.
 
  2.8.1.2   Each DM program shall utilize evidence-based clinical practice guidelines (hereafter referred to as the guidelines) that have been formally adopted by the CONTRACTOR’s Quality Management/Quality Improvement (QM/QI) committee or other clinical committee and patient empowerment strategies to support the provider-patient relationship and the plan of care. For the conditions listed in 2.8.1.1.1 through 2.8.1.1.9, the guidelines shall include a requirement to conduct a mental health and substance abuse screening. The DM programs for bipolar disorder, major depression, and schizophrenia shall include the use of the evidence-based practice for co-occurring disorders.
 
  2.8.1.3   The DM programs shall emphasize the prevention of exacerbation and complications of the conditions as evidenced by decreases in emergency room utilization and inpatient hospitalization and/or improvements in condition-specific health status indicators.
 
  2.8.1.4   The CONTRACTOR shall develop and maintain DM program policies and procedures, which shall include program descriptions. These policies and procedures shall include, for each of the conditions listed above, the following:
 
  2.8.1.4.1   The definition of the target population;
 
  2.8.1.4.2   Member identification strategies, which shall not exclude CHOICES members, including dual eligible CHOICES members;
 
  2.8.1.4.3   The guidelines;
 
  2.8.1.4.4   Written description of the stratification levels for each of the conditions, including member criteria and associated interventions;
 
  2.8.1.4.5   Program content;
 
  2.8.1.4.6   Targeted methods for informing and educating members which may include, but shall not be limited to mailing educational materials;
 
  2.8.1.4.7   Methods for informing and educating providers; and
 
  2.8.1.4.8   Program evaluation.
 
  2.8.1.5   As part of its DM program policies and procedures, the CONTRACTOR shall also address how the DM programs will coordinate with MCO case management activities, in particular for members who would benefit from both.
 
  2.8.1.6   The CONTRACTOR’s DM and care coordination policies and procedures shall address how the CONTRACTOR shall ensure that upon enrollment into CHOICES, disease management activities are integrated with CHOICES care coordination processes and functions, and that the member’s assigned care coordinator has primary responsibility for coordination of all the member’s physical health,

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      behavioral health, and long-term care services, including appropriate management of conditions specified in 2.8.1.1. If a CHOICES member has one or more of the conditions specified in Section 2.8.1.1, the member’s care coordinator may use the CONTRACTOR’s applicable DM tools and resources, including staff with specialized training, to help manage the member’s condition and shall integrate the use of these DM tools and resources with care coordination. DM staff shall supplement but not supplant the role and responsibilities of the member’s care coordinator/care coordination team. The CONTRACTOR’s policies and procedures shall also include at a minimum how the CONTRACTOR will address the following for CHOICES members:
 
  2.8.1.6.1   Notify the member’s care coordinator of the member’s participation in a DM program;
 
  2.8.1.6.2   Provide to the member’s care coordinator information about the member collected through the DM program;
 
  2.8.1.6.3   Provide to the care coordinator any educational materials given to the member through the DM program;
 
  2.8.1.6.4   Ensure that the care coordinator reviews the information noted in Section 2.8.1.6.3 above verbally with the member and with the member’s paid and/or unpaid caregiver and coordinates any necessary follow-up that may be needed regarding the DM program such as scheduling screenings or appointments;
 
  2.8.1.6.5   Ensure that the care coordinator integrates into the member’s plan of care aspects of the DM program that would help to better manage the member’s condition; and
 
  2.8.1.6.6   Ensure that the member’s care coordinator shall be responsible for coordinating with the member’s providers regarding the development and implementation of an individualized treatment plan which shall be integrated into the member’s plan of care and which shall include monitoring the member’s condition, helping to ensure compliance with treatment protocols, and to the extent appropriate, lifestyle changes which will help to better ensure management of the member’s condition (see Section 2.9.6 of this Agreement).
 
  2.8.1.7   The CONTRACTOR shall implement DM programs specific to CHOICES members in accordance with the following schedule:
 
  2.8.1.7.1   After the second calendar quarter following CHOICES implementation in the Grand Region covered by this Agreement, the CONTRACTOR shall implement DM programs for CHOICES members for four of the six disease management conditions listed in Sections 2.8.1.1.2, 2.8.1.1.3, 2.8.1.1.5, 2.8.1.1.6, 2.8.1.1.8, and 2.8.8).
 
  2.8.1.7.2   After the fourth calendar quarter following CHOICES implementation in the Grand Region covered by this Agreement, the CONTRACTOR shall implement DM programs for CHOICES members for the two DM conditions listed in Sections 2.8.1.1.2, 2.8.1.1.3, 2.8.1.1.5, 2.8.1.1.6, 2.8.1.1.8, and 2.8.8 for which the CONTRACTOR has not developed a DM program for CHOICES members.

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  2.8.1.7.3   After the sixth calendar quarter following CHOICES implementation in the Grand Region covered by this Agreement, the CONTRACTOR shall implement DM programs for CHOICES members for the three DM conditions listed in Sections 2.8.1.1.4, 2.8.1.1.7, and 2.8.1.1.9, for a total of nine (9) DM programs for CHOICES members.
2.8.2 Member Identification Strategies
  2.8.2.1   The CONTRACTOR shall have a systematic method of identifying and enrolling eligible members in each DM program, including CHOICES members, through the same processes used for identification of non-CHOICES members and the CHOICES care coordination process..
 
  2.8.2.2   The CONTRACTOR shall operate its disease management programs using an “opt out” methodology, meaning that disease management services shall be provided to eligible members unless they specifically ask to be excluded.
2.8.3 Stratification
As part of the DM programs, the CONTRACTOR shall classify eligible members into stratification levels according to condition severity or other clinical or member-provided information which, for members enrolled in the CHOICES program shall also include stratification by the type of setting in which long-term care services are delivered, i.e., nursing facility, community-based residential alternative, or home-based. The DM programs shall tailor the program content and education activities for each stratification level. For CHOICES members, this shall include targeted interventions based on the setting in which the member resides.
2.8.4 Program Content
Each DM program shall include the development of treatment plans, as described in NCQA Disease Management program content, that serve as the outline for all of the activities and interventions in the program. At a minimum the activities and interventions associated with the treatment plan shall address condition monitoring, patient adherence to the treatment plan, consideration of other co-morbidities, and condition-related lifestyle issues. For CHOICES members, appropriate elements of the treatment plan shall be individualized and integrated into the member’s plan of care to facilitate better management of the member’s condition.
2.8.5 Informing and Educating Members
The DM programs shall educate members and/or their caregivers regarding their particular condition(s) and needs. This information shall be provided upon enrollment in the DM program. The DM programs shall educate members to increase their understanding of their condition(s), the factors that impact their health status (e.g., diet and nutrition, lifestyle, exercise, medication compliance), and to empower members to be more effective in self-care and management of their health so they:
  2.8.5.1   Are proactive and effective partners in their care;
 
  2.8.5.2   Understand the appropriate use of resources needed for their care;

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  2.8.5.3   Identify precipitating factors and appropriate responses before they require more acute intervention; and
 
  2.8.5.4   Are compliant and cooperative with the recommended treatment plan.
2.8.6 Informing and Educating Providers
As part of the DM programs, the CONTRACTOR shall educate providers regarding the guidelines and shall distribute the guidelines to providers who are likely to treat enrollees with the DM conditions. This includes, but is not limited to, PCPs and specialists involved in treating that particular condition. The CONTRACTOR shall also provide each PCP with a list of their patients enrolled in each DM program upon the member’s initial enrollment and at least annually thereafter. The CONTRACTOR shall provide specific information to the provider concerning how the program(s) works. The DM’s provider education shall be designed to increase the providers’ adherence to the guidelines in order to improve the members’ conditions.
2.8.7 Program Evaluation (Satisfaction and Effectiveness)
  2.8.7.1   The CONTRACTOR shall evaluate member satisfaction with the DM services (as described by NCQA) by systematically analyzing feedback from members and analyzing member complaints and inquiries at least annually. The feedback on satisfaction shall be specific to DM programs.
 
  2.8.7.1.1   A written summary, of member satisfaction with the DM program, shall be included in the annual DM report.
 
  2.8.7.2   The CONTRACTOR shall establish measurable benchmarks and goals for each DM program and shall evaluate the programs using these benchmarks and goals. These benchmarks and goals shall be specific to each condition but should include:
 
  2.8.7.2.1   Performance measured against at least two important clinical aspects of the guidelines associated with each DM program;
 
  2.8.7.2.2   The rate of emergency department utilization, inpatient hospitalization, and nursing facility admission;
 
  2.8.7.2.3   Neonatal Intensive Care Unit (NICU) days for births associated with members enrolled in the maternity care management program;
 
  2.8.7.2.4   Appropriate HEDIS measures;
 
  2.8.7.2.5   The passive participation rates (as defined by NCQA) and the number of individuals participating in each level of each of the DM programs;
 
  2.8.7.2.6   Cost savings;
 
  2.8.7.2.7   Member adherence to treatment plans; and
 
  2.8.7.2.8   Provider adherence to the guidelines.

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  2.8.7.3   For CHOICES members, measures of member satisfaction and effectiveness shall be reported by the type of setting in which long-term care services are delivered in order to facilitate comparison across long-term care service delivery settings.
 
  2.8.7.4   The CONTRACTOR shall report on DM activities as required in Section 2.30.5.
2.8.8 Obesity Disease Management
In addition to the aforementioned DM program requirements, the CONTRACTOR shall have a DM program for obesity that is provided as a cost effective alternative service (see Section 2.6.5). The CONTRACTOR may fulfill this requirement by entering into a provider agreement with Weight Watchers and then referring/authorizing eligible obese and overweight members to participate in a Weight Watchers program. If the CONTRACTOR identifies another weight management program as the cost effective alternative service, the CONTRACTOR shall include a narrative of the program (including target population and description of services) as part of its quarterly disease management report (see Section 2.30.5.1) applicable to the quarter in which the program was implemented.
11. Section 2.9 shall be deleted in its entirety and replaced with the following:
2.9 SERVICE COORDINATION
2.9.1 General
  2.9.1.1   The CONTRACTOR shall be responsible for the management, coordination, and continuity of care for all its TennCare members and shall develop and maintain policies and procedures to address this responsibility. For CHOICES members, these policies and procedures shall specify the role of the care coordinator/care coordination team in conducting these functions (see Section 2.9.6).
 
  2.9.1.2   The CONTRACTOR shall:
 
  2.9.1.2.1   Coordinate care among PCPs, specialists, behavioral health providers, and long-term care providers;
 
  2.9.1.2.2   Perform reasonable preventive health case management services, have mechanisms to assess the quality and appropriateness of services furnished, and provide appropriate referral and scheduling assistance;
 
  2.9.1.2.3   Monitor members with ongoing medical or behavioral health conditions;
 
  2.9.1.2.4   Provide care coordination to CHOICES members (see Section 2.9.6);
 
  2.9.1.2.5   Identify members using emergency department services inappropriately to assist in scheduling follow-up care with PCPs and/or appropriate specialists to improve continuity of care and establish a medical home;
 
  2.9.1.2.6   Maintain and operate a formalized hospital and/or institutional discharge planning program;

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  2.9.1.2.7   Coordinate hospital and/or institutional discharge planning that includes post- discharge care, as appropriate;
 
  2.9.1.2.8   Maintain an internal tracking system that identifies the current preventive services screening status and pending preventive services screening due dates for each member; and
 
  2.9.1.2.9   Authorize services provided by non-contract providers, as required in this Agreement (see, e.g., Section 2.13).
2.9.2 Transition of New Members
  2.9.2.1   In the event an enrollee entering the CONTRACTOR’s MCO, either as a new TennCare enrollee or transferring from another MCO, is receiving medically necessary covered services in addition to or other than prenatal services (see below for enrollees receiving only prenatal services) the day before enrollment, the CONTRACTOR shall be responsible for the costs of continuation of such medically necessary services, without any form of prior approval and without regard to whether such services are being provided by contract or non-contract providers. Except as specified in this Section 2.9.2 or in Sections 2.9.3 or 2.9.6, this requirement shall not apply to long-term care services.
 
  2.9.2.1.1   For medically necessary covered services, other than long-term care services, being provided by a non-contract provider, the CONTRACTOR shall provide continuation of such services for up to ninety (90) calendar days or until the member may be reasonably transferred without disruption to a contract provider, whichever is less. The CONTRACTOR may require prior authorization for continuation of services beyond thirty (30) calendar days; however, the CONTRACTOR is prohibited from denying authorization solely on the basis that the provider is a non-contract provider.
 
  2.9.2.1.2   For medically necessary covered services, other than long-term care services, being provided by a contract provider, the CONTRACTOR shall provide continuation of such services from that provider but may require prior authorization for continuation of such services from that provider beyond thirty (30) calendar days. The CONTRACTOR may initiate a provider change only as otherwise specified in this Agreement.
 
  2.9.2.1.3   For medically necessary covered long-term care services for CHOICES members who are new to both TennCare and CHOICES, the CONTRACTOR shall provide long-term care services as specified in Sections 2.9.6.2.4 and 2.9.6.2.5.
 
  2.9.2.1.4   For covered long-term care services for CHOICES members who are transferring from another MCO, the CONTRACTOR shall be responsible for continuing to provide covered long-term care services, including both HCBS authorized by the transferring MCO and nursing facility services, without regard to whether such services are being provided by contract or non-contract providers.
 
  2.9.2.1.4.1   For a member in CHOICES Group 2 or 3, the CONTRACTOR shall continue HCBS authorized by the transferring MCO for a minimum of thirty (30) days after the member’s enrollment and thereafter shall not reduce these services unless a care coordinator has conducted a comprehensive needs assessment and

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      developed a plan of care, and the CONTRACTOR has authorized and initiated HCBS in accordance with the member’s new plan of care. If a member in CHOICES Group 2 or 3 is receiving short-term nursing facility care, the CONTRACTOR shall continue to provide nursing facility services to the member in accordance with the level of nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12). For a member in Group 1, the CONTRACTOR shall provide nursing facility services to the member in accordance with the level of nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12); however, the member may be transitioned to the community in accordance with Section 2.9.6.8 of this Agreement.
 
  2.9.2.1.4.2   For a member in CHOICES Group 2 or 3, within thirty (30) days of notice of the member’s enrollment with the CONTRACTOR, a care coordinator shall conduct a face-to-face visit (see Section 2.9.6.2.5), including a comprehensive needs assessment (see Section 2.9.6.5), and develop a plan of care (see Section 2.9.6.6), and the CONTRACTOR shall authorize and initiate HCBS in accordance with the new plan of care (see Section 2.9.6.2.5). If a member in Group 2 or 3 is receiving short-term nursing facility care on the date of enrollment with the CONTRACTOR, a care coordinator shall complete a face-to-face visit prior to the expiration date of the level of nursing facility services approved by TENNCARE, but no later than thirty (30) days after enrollment to determine appropriate needs assessment and care planning activities (see Section 2.9.6.2.5 for members who will be discharged from the nursing facility and remain in Group 2 or 3 and Section 2.9.6.2.4 for members who will remain in the nursing facility and be enrolled in Group 1). If the expiration date for the level of nursing facility services approved by TENNCARE occurs prior to thirty (30) days after enrollment, and the CONTRACTOR is unable to conduct the face-to-face visit prior to the expiration date, the CONTRACTOR shall be responsible for facilitating discharge to the community or enrollment in Group 1, whichever is appropriate.
 
  2.9.2.1.4.3   If at any time before conducting a comprehensive needs assessment for a member in CHOICES Group 2 or 3 the CONTRACTOR becomes aware of an increase in the member’s needs, a care coordinator shall immediately conduct a comprehensive needs assessment and update the member’s plan of care, and the CONTRACTOR shall initiate the change in services within ten (10) days of becoming aware of the increase in the member’s needs.
 
  2.9.2.1.4.4   For a member in CHOICES Group 1 who, at the time of enrollment with the CONTRACTOR, has resided in a nursing facility for less than ninety (90) days, a care coordinator shall conduct a face-to-face in-facility visit within thirty (30) days of the member’s enrollment with the CONTRACTOR and conduct a needs assessment as determined necessary by the CONTRACTOR (see Section 2.9.6.5). For a member in CHOICES Group 1 who, at the time of enrollment with the CONTRACTOR, has resided in a nursing facility for ninety (90) days or more, a care coordinator shall conduct a face-to-face in-facility visit within sixty (60) days of the member’s enrollment with the CONTRACTOR and conduct a needs assessment as determined necessary by the CONTRACTOR (see Section 2.9.6.5).

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  2.9.2.1.4.5   The CONTRACTOR shall facilitate a seamless transition to new services and/or providers, as applicable, in the plan of care developed by the CONTRACTOR without any disruption in services.
 
  2.9.2.1.4.6   The CONTRACTOR shall not:
 
  2.9.2.1.4.6.1   Transition nursing facility residents or residents of community-based residential alternatives to another facility unless (1) the member or his/her representative specifically requests to transition, which shall be documented in the member’s file, (2) the member or his/her representative provides written consent to transition based on quality or other concerns raised by the CONTRACTOR, which shall not include the nursing facility’s rate of reimbursement; or (3) the facility where the member is residing is not a contract provider; if the community-based residential facility where the member is currently residing is not a contract provider, the CONTRACTOR shall provide continuation of services in such facility for at least thirty (30) days, which shall be extended as necessary to ensure continuity of care pending the facility’s contracting with the CONTRACTOR or the member’s transition to a contract facility; if the member is transitioned to a contract facility, the CONTRACTOR shall facilitate a seamless transition to the new facility; if the nursing facility where the member is currently residing is a non-contract provider, the CONTRACTOR shall (a) authorize continuation of the services pending enrollment of the facility as a contract provider (except a facility excluded for a 2-year period when the facility has withdrawn from Medicaid participation); (b) authorize continuation of the services pending facilitation of the member’s transition to a contract facility, subject to the member’s agreement with such transition; or (c) may continue to reimburse services from the non-contract nursing facility in accordance with TennCare rules and regulations;
 
  2.9.2.1.4.6.2   Transition Group 1 members to HCBS unless the member chooses to receive HCBS as an alternative to nursing facility care and is enrolled in CHOICES Group 2 (see Section 2.9.6.8 for requirements regarding nursing facility to community transition);
 
  2.9.2.1.4.6.3   Admit a member in CHOICES Group 2 to a nursing facility unless (1) the member requires a short-term nursing facility care stay; (2) the member chooses to transition to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR determines that it cannot safely and effectively meet the needs of the member and within the member’s cost neutrality cap, and the member agrees to transition to a nursing facility and enroll in Group 1;
 
  2.9.2.1.4.6.4   Admit a member enrolled in CHOICES Group 3 to a nursing facility unless: (1) the member meets nursing facility level of care and is expected to require nursing facility services for ninety (90) days or less; or (2) the member meets nursing facility level of care, is expected to require nursing facility services for more than ninety (90) days and chooses to transition to a nursing facility and enroll in Group 1; or
 
  2.9.2.1.4.6.5   Transition members in Group 2 or 3 to another HCBS provider for continuing services unless the current HCBS provider is not a contract provider; if the current HCBS provider is not a contract provider, the CONTRACTOR shall

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      provide continuation of HCBS from that provider for at least thirty (30) days, which shall be extended as necessary to ensure continuity of care pending the provider’s contracting with the CONTRACTOR or the member’s transition to a contract provider; if the member is transitioned to a contract provider, the CONTRACTOR shall facilitate a seamless transition to the new provider.
 
  2.9.2.1.5   For CHOICES members who are transferring to the CONTRACTOR’s MCO serving the Grand Region covered by this Agreement from a Grand Region where CHOICES has not yet been implemented, the CONTRACTOR shall be responsible for continuing to provide covered long-term care services, including both HCBS in the member’s approved HCBS E/D waiver plan of care and nursing facility services.
 
  2.9.2.1.5.1   For CHOICES members in Group 2, the CONTRACTOR shall be responsible for continuing to provide HCBS in accordance with the member’s approved HCBS E/D waiver plan of care for a minimum of thirty (30) calendar days after enrollment; thereafter the CONTRACTOR shall not reduce the member’s HCBS unless a care coordinator has conducted a comprehensive needs assessment and developed a plan of care, and the CONTRACTOR has authorized and initiated HCBS in accordance with the member’s new plan of care. If a member in CHOICES Group 2 is receiving short-term nursing facility care, the CONTRACTOR shall continue to provide nursing facility services to the member in accordance with the level of nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12). For a member in Group 1, the CONTRACTOR shall provide nursing facility services to the member in accordance with the level of nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12); however, the member may be transitioned to the community in accordance with Section 2.9.6.8 of this Agreement.
 
  2.9.2.1.5.2   For a member in CHOICES Group 2, within thirty (30) days of notice of the member’s enrollment, a care coordinator shall conduct a face-to-face visit (see Section 2.9.6.2.5), including a comprehensive needs assessment (see Section 2.9.6.5), and develop a plan of care (see Section 2.9.6.6), and the CONTRACTOR shall authorize and initiate HCBS in accordance with the new plan of care (see Section 2.9.6.2.5). If the member is receiving short-term nursing facility care on the date of enrollment with the CONTRACTOR, a care coordinator shall complete a face-to-face visit prior to the expiration date of the level of nursing facility services approved by TENNCARE, and within no more than thirty (30) days of the member’s enrollment, to determine appropriate needs assessment and care planning activities (see Section 2.9.6.2.5 for members who will be discharged for the nursing facility and remain in Group 2 and Section 2.9.6.2.4 for members who will remain in the nursing facility and be enrolled in Group 1). If the expiration date for the level of nursing facility services approved by TENNCARE occurs prior to thirty (30) days after enrollment, and the CONTRACTOR is unable to conduct the face-to-face visit prior to the expiration date, the CONTRACTOR shall be responsible for facilitating discharge to the community or enrollment in Group 1, whichever is appropriate.
 
  2.9.2.1.5.3   If at any time before conducting the comprehensive needs assessment for a member in CHOICES Group 2 the CONTRACTOR becomes aware of an increase in the member’s needs, a care coordinator shall immediately conduct a comprehensive needs assessment and update the member’s plan of

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      care, and the CONTRACTOR shall initiate the change in services within ten (10) days of becoming aware of the change in the member’s needs.
 
  2.9.2.1.5.4   For a member in CHOICES Group 1 who, at the time of enrollment with the CONTRACTOR, has resided in a nursing facility for less than ninety (90) days, a care coordinator shall conduct a face-to-face in-facility visit within thirty (30) days of the member’s enrollment with the CONTRACTOR and conduct a needs assessment as determined necessary by the CONTRACTOR (see Section 2.9.6.5). For a member in CHOICES Group 1 who, at the time of enrollment with the CONTRACTOR, has resided in a nursing facility for ninety (90) days or more, a care coordinator shall conduct a face-to-face in-facility visit within sixty (60) days of the member’s enrollment with the CONTRACTOR and conduct a needs assessment as determined necessary by the CONTRACTOR (see Section 2.9.6.5).
 
  2.9.2.1.5.5   The CONTRACTOR shall facilitate a seamless transition to new services and/or providers, as applicable, in the plan of care developed by the CONTRACTOR without any disruption in services.
 
  2.9.2.1.5.6   The CONTRACTOR shall not:
 
  2.9.2.1.5.6.1   Transition nursing facility residents or residents of community-based residential alternatives to another facility unless (1) the member or his/her representative specifically requests to transition, which shall be documented in the member’s file, (2) the member or his/her representative provides written consent to transition based on quality or other concerns raised by the CONTRACTOR, which shall not include the nursing facility’s rate of reimbursement; or (c) the facility where the member is residing is not a contract provider; if the community-based residential facility where the member is currently residing is not a contract provider, the CONTRACTOR shall provide continuation of services in such facility for at least thirty (30) days, which shall be extended as necessary to ensure continuity of care pending the facility’s contracting with the CONTRACTOR or the member’s transition to a contract facility; if the member is transitioned to a contract facility, the CONTRACTOR shall facilitate a seamless transition to the new facility; if the nursing facility where the member is currently residing is a non-contract provider, the CONTRACTOR shall (a) authorize continuation of the services pending enrollment of the facility as a contract provider (except a facility excluded for a 2-year period when the facility has withdrawn from Medicaid participation); (b) authorize continuation of the services pending facilitation of the member’s transition to a contract facility, subject to the member’s agreement with such transition; or (c) may continue to reimburse services from the non-contract nursing facility in accordance with TennCare rules and regulations;
 
  2.9.2.1.5.6.2   Transition Group 1 members to HCBS unless the member chooses to receive HCBS as an alternative to nursing facility care and is enrolled in CHOICES Group 2 (see Section 2.9.6.8 for requirements regarding nursing facility to community transition);

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  2.9.2.1.5.6.3   Admit a member in CHOICES Group 2 to a nursing facility unless (1) the member requires a short-term nursing facility care stay; (2) the member chooses to transition to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR determines that it cannot safely and effectively meet the needs of the member and within the member’s cost neutrality cap and the member agrees to transition to a nursing facility and enroll in Group 1; or
 
  2.9.2.1.5.6.4   Transition members in Group 2 to another HCBS provider for continuing services unless the current HCBS provider is not a contract provider; if the current HCBS provider is not a contract provider, the CONTRACTOR shall provide continuation of HCBS from that provider for at least thirty (30) days, which shall be extended as necessary to ensure continuity of care pending the provider’s contracting with the CONTRACTOR or the member’s transition to a contract provider; if the member is transitioned to a contract provider, the CONTRACTOR shall facilitate a seamless transition to the new provider.
 
  2.9.2.2   In the event an enrollee entering the CONTRACTOR’s MCO, either as a new TennCare enrollee or transferring from another MCO, is in her first trimester of pregnancy and is receiving medically necessary covered prenatal care services the day before enrollment, the CONTRACTOR shall be responsible for the costs of continuation of such medically necessary prenatal care services, including prenatal care, delivery, and post-natal care, without any form of prior approval and without regard to whether such services are being provided by a contract or non-contract provider.
 
  2.9.2.2.1   If the member is receiving services from a non-contract provider, the CONTRACTOR shall be responsible for the costs of continuation of medically necessary covered prenatal services, without any form of prior approval, until such time as the CONTRACTOR can reasonably transfer the member to a contract provider without impeding service delivery that might be harmful to the member’s health.
 
  2.9.2.2.2   If the member is receiving services from a contract provider, the CONTRACTOR shall be responsible for the costs of continuation of medically necessary covered prenatal services from that provider, without any form of prior approval, through the postpartum period.
 
  2.9.2.3   In the event an enrollee entering the CONTRACTOR’s MCO, either as a new TennCare enrollee or transferring from another MCO, is in her second or third trimester of pregnancy and is receiving medically necessary covered prenatal care services the day before enrollment, the CONTRACTOR shall be responsible for providing continued access to the prenatal care provider (whether contract or noncontract provider) through the postpartum period, without any form of prior approval.
 
  2.9.2.4   If a member enrolls in the CONTRACTOR’s MCO from another MCO, the CONTRACTOR shall immediately contact the member’s previous MCO and request the transfer of “transition of care data” as specified by TENNCARE. If the CONTRACTOR is contacted by another MCO requesting “transition of care data” for a member who has transferred from the CONTRACTOR to the requesting MCO (as verified by the CONTRACTOR), the CONTRACTOR shall provide such data in the timeframe and format specified by TENNCARE.

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  2.9.2.5   If the CONTRACTOR becomes aware that a CHOICES member will be transferring to another MCO, the CONTRACTOR (including, but not limited to the member’s care coordinator) shall work with the other MCO in facilitating a seamless transition for that member. If a member in Group 2 or 3 is transferring to a Grand Region where CHOICES has not been implemented, the care coordinator shall provide the local Area Agency on Aging and Disability (AAAD) with the member’s plan of care and other information specified by TENNCARE within the timeframe and in the format specified by TENNCARE and shall work with the AAAD to facilitate a seamless transition for that member.
 
  2.9.2.6   The CONTRACTOR shall ensure that any member entering the CONTRACTOR’s MCO is held harmless by the provider for the costs of medically necessary covered services except for applicable TennCare cost sharing and patient liability amounts (see Section 2.6.7 of this Agreement).
 
  2.9.2.7   The CONTRACTOR shall develop and maintain policies and procedures regarding the transition of new members.
2.9.3 Transition of Members Receiving Long-Term Care Services at the Time of CHOICES Implementation
  2.9.3.1   For each member who is enrolling in CHOICES as of the date of CHOICES implementation in the Grand Region covered by this Agreement, as identified by TENNCARE (herein referred to as “transitioning CHOICES members”), the CONTRACTOR shall assign a care coordinator prior to the first face-to-face visit. If the face-to-face visit will not occur within ten (10) days after the implementation of CHOICES, the CONTRACTOR shall send the member written notification within ten (10) calendar days of implementation that explains how the member can reach the care coordination unit for assistance with concerns or questions pending the assignment of a specific care coordinator.
 
  2.9.3.2   For each transitioning CHOICES member, the CONTRACTOR shall be responsible for the costs of continuing to provide covered long-term care services previously authorized by TENNCARE or its designee, including, as applicable, HCBS in the member’s approved HCBS E/D waiver plan of care and nursing facility services without regard to whether such services are being provided by contract or noncontract providers.
 
  2.9.3.3   For members in Group 2 the CONTRACTOR shall continue HCBS in the member’s approved HCBS E/D waiver plan of care except case management for a minimum of thirty (30) days after the member’s enrollment and thereafter shall not reduce HCBS unless the member’s care coordinator has conducted a comprehensive needs assessment and developed a plan of care and the CONTRACTOR has authorized and initiated HCBS in accordance with the member’s new plan of care. If a member in CHOICES Group 2 is receiving short-term nursing facility care, the CONTRACTOR shall continue to provide nursing facility services to the member in accordance with the level of nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12).

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  2.9.3.4   For a member in CHOICES Group 2, within ninety (90) days of CHOICES implementation, the member’s care coordinator shall conduct a face-to-face visit (see Section 2.9.6.2.5), including a comprehensive needs assessment (see Section 2.9.6.5), and develop a plan of care (see Section 2.9.6.6), and the CONTRACTOR shall authorize and initiate HCBS in accordance with the new plan of care. If a member in Group 2 is receiving short-term nursing facility care on the date of enrollment with the CONTRACTOR the member’s care coordinator shall complete a face-to-face visit prior to the expiration date of the level of nursing services approved by TENNCARE, but no more than ninety (90) days after CHOICES implementation, to determine appropriate needs assessment and care planning activities (see Section 2.9.6.2.5 for members who will be discharged from the nursing facility and remain in Group 2 or 3 and Section 2.9.6.2.4 for members who will remain in the nursing facility and be enrolled in Group 1). If the expiration date for the level of nursing facility services approved by TENNCARE occurs prior to ninety (90) days after CHOICES implementation, and the CONTRACTOR is unable to conduct the face-to- face visit prior to the expiration date, the CONTRACTOR shall be responsible for facilitating discharge to the community or enrollment in Group 1, whichever is appropriate.
 
  2.9.3.5   If at any time before conducting a comprehensive needs assessment for a member in CHOICES Group 2 the CONTRACTOR becomes aware of an increase in the member’s needs, the member’s care coordinator shall immediately conduct a comprehensive needs assessment and update the member’s plan of care, and the CONTRACTOR shall initiate the change in services within ten (10) days of becoming aware of the change in the member’s needs.
 
  2.9.3.6   The CONTRACTOR shall provide nursing facility services to a member in Group 1 in accordance with the level of nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12); however, the member may be transitioned to the community in accordance with Section 2.9.6.8 of this Agreement.
 
  2.9.3.7   For a member in CHOICES Group 1 who, at the time of enrollment with the CONTRACTOR, has resided in a nursing facility for less than ninety (90) days, the member’s care coordinator shall conduct a face-to-face in-facility visit within ninety (90) days of the implementation of CHOICES and conduct a needs assessment as determined necessary by the CONTRACTOR (see Section 2.9.6.5.1). For a member in CHOICES Group 1 who, at the time of implementation of CHOICES, has resided in a nursing facility for ninety (90) days or more, the member’s care coordinator shall conduct a face-to-face in-facility visit within six (6) months of the member’s enrollment with the CONTRACTOR and conduct a needs assessment as determined necessary by the CONTRACTOR (see Section 2.9.6.5.1).
 
  2.9.3.8   The CONTRACTOR shall facilitate a seamless transition to new services and/or providers, as applicable, in the plan of care developed by the CONTRACTOR without any disruption in services.
 
  2.9.3.9   The CONTRACTOR shall not:
 
  2.9.3.9.1   Transition nursing facility residents or residents of community-based residential alternatives to another facility unless (1) the member or his/her representative specifically requests to transition, which shall be documented in the member’s file,

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      (2) the member or his/her representative provides written consent to transition based on quality or other concerns raised by the CONTRACTOR, which shall not include the nursing facility’s rate of reimbursement; or (3) the facility where the member is residing is not a contract provider; if the community-based residential facility where the member is currently residing is not a contract provider, the CONTRACTOR shall provide continuation of services in such facility for at least thirty (30) days, which shall be extended as necessary to ensure continuity of care pending the facility’s contracting with the CONTRACTOR or the member’s transition to a contract facility; if the member is transitioned to a contract facility, the CONTRACTOR shall facilitate a seamless transition to the new facility; if the nursing facility where the member is currently residing is a non-contract provider, the CONTRACTOR shall (a) authorize continuation of the services pending enrollment of the facility as a contract provider (except a facility excluded for a 2-year period when the facility has withdrawn from Medicaid participation); (b) authorize continuation of the services pending facilitation of the member’s transition to a contract facility, subject to the member’s agreement with such transition; or (c) may continue to reimburse services from the non-contract nursing facility in accordance with TennCare rules and regulations;
 
  2.9.3.9.2   Transition Group 1 members to HCBS unless the member chooses to receive HCBS as an alternative to nursing facility care and is enrolled in CHOICES Group 2 (see Section 2.9.6.8 for requirements regarding nursing facility to community transition);
 
  2.9.3.9.3   Admit a member in CHOICES Group 2 to a nursing facility unless (1) the member requires a short-term nursing facility care stay; (2) the member chooses to transition to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR determines that it cannot safely and effectively meet the needs of the member and within the member’s cost neutrality cap, and the member agrees to transition to a nursing facility and enroll in Group 1; or
 
  2.9.3.9.4   Transition members in Group 2 or 3 to another HCBS provider for continuing services unless the current HCBS provider is not a contract provider; if the current HCBS provider is not a contract provider, the CONTRACTOR shall provide continuation of HCBS from that provider for at least thirty (30) days, which shall be extended as necessary to ensure continuity of care pending the provider’s contracting with the CONTRACTOR or the member’s transition to a contract provider; if the member is transitioned to a contract provider, the CONTRACTOR shall facilitate a seamless transition to the new provider.
2.9.4 Transition of Care
  2.9.4.1   The CONTRACTOR shall actively assist members with chronic or acute medical or behavioral health conditions, members who are receiving long-term care services, and members who are pregnant in transitioning to another provider when a provider currently treating their chronic or acute medical or behavioral health condition, currently providing their long-term care services, or currently providing prenatal services has terminated participation with the CONTRACTOR. For CHOICES members, this assistance shall be provided by the member’s care coordinator/care coordination team.

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  2.9.4.1.1   Except as provided below regarding members who are in their second or third trimester of pregnancy, the CONTRACTOR shall provide continuation of such provider for up to ninety (90) calendar days or until the member may be reasonably transferred to another provider without disruption of care, whichever is less.
 
  2.9.4.1.2   For members in their second or third trimester of pregnancy, the CONTRACTOR shall allow continued access to the member’s prenatal care provider and any provider currently treating the member’s chronic or acute medical or behavioral health condition or currently providing long-term care services, through the postpartum period.
 
  2.9.4.2   The CONTRACTOR shall actively assist members in transitioning to another provider when there are changes in providers. The CONTRACTOR shall have transition policies that, at a minimum, include the following:
 
  2.9.4.2.1   A schedule which ensures transfer does not create a lapse in service;
 
  2.9.4.2.2   For CHOICES members in Groups 2 and 3, the requirement for a HCBS provider that is no longer willing or able to provide services to a member to cooperate with the member’s care coordinator to facilitate a seamless transition to another HCBS provider (see Section 2.12.12.1) and to continue to provide services to the member until the member has been transitioned to another HCBS provider, as determined by the CONTRACTOR, or as otherwise directed by the CONTRACTOR (see Section 2.12.12.2);
 
  2.9.4.2.3   A mechanism for timely information exchange (including transfer of the member record);
 
  2.9.4.2.4   A mechanism for assuring confidentiality;
 
  2.9.4.2.5   A mechanism for allowing a member to request and be granted a change of provider;
 
  2.9.4.2.6   An appropriate schedule for transitioning members from one (1) provider to another when there is medical necessity for ongoing care.
 
  2.9.4.2.7   Specific transition language on the following special populations:
 
  2.9.4.2.7.1   Children who are SED;
 
  2.9.4.2.7.2   Adults who are SPMI;
 
  2.9.4.2.7.3   Persons who have addictive disorders;
 
  2.9.4.2.7.4   Persons who have co-occurring disorders of both mental health and substance abuse disorders; and
 
  2.9.4.2.7.5   Persons with behavioral health conditions who also have a developmental disorder (dually diagnosed). These members shall be allowed to remain with their providers of the services listed below for the minimum time frames set out below as long as the services continue to be medically necessary. The CONTRACTOR may shorten these transition time frames only when the provider of services is no

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      longer available to serve the member or when a change in providers is agreed to in writing by the member.
 
  2.9.4.2.7.5.1   Mental health case management: three (3) months;
 
  2.9.4.2.7.5.2   Psychiatrist: three (3) months;
 
  2.9.4.2.7.5.3   Outpatient behavioral health therapy: three (3) months;
 
  2.9.4.2.7.5.4   Psychosocial rehabilitation and supported employment: three (3) months; and
 
  2.9.4.2.7.5.5   Psychiatric inpatient or residential treatment and supported housing: six (6) months.
2.9.5 MCO Case Management
  2.9.5.1   The CONTRACTOR shall maintain an MCO case management program that includes the following components:
 
  2.9.5.1.1   A systematic approach to identify eligible members;
 
  2.9.5.1.2   Assessment of member needs;
 
  2.9.5.1.3   Development of an individualized plan of care;
 
  2.9.5.1.4   Implementation of the plan of care, including coordination of care that actively links the member to providers and support services; and
 
  2.9.5.1.5   Program Evaluation (Satisfaction and Effectiveness).
 
  2.9.5.2   The CONTRACTOR shall provide MCO case management to members who are at high risk or have unique, chronic, or complex needs. This shall include but not be limited to members with co-occurring mental illness and substance abuse and/or co- morbid physical health and behavioral health conditions.
 
  2.9.5.3   The CONTRACTOR has the option of allowing members to be enrolled in both MCO case management and a disease management program.
 
  2.9.5.4   The CONTRACTOR shall ensure that, upon a member’s enrollment in CHOICES, MCO case management activities are integrated with CHOICES care coordination processes and functions, and that the member’s assigned care coordinator has primary responsibility for coordination of all the member’s physical health, behavioral health, and long-term care needs. The care coordinator may use resources and staff from the CONTRACTOR’s MCO case management program, including persons with specialized expertise in areas such as behavioral health, to supplement but not supplant the role and responsibilities of the member’s care coordinator/care coordination team.
 
  2.9.5.5   Eligible members shall be offered MCO case management services. However, member participation shall be voluntary.

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  2.9.5.6   The CONTRACTOR shall develop a process to inform members and providers about the availability of MCO case management and to inform the member’s PCP and/or appropriate specialist when a member has been assigned to the MCO case management program.
 
  2.9.5.7   The CONTRACTOR shall use utilization data, including pharmacy data provided by TENNCARE or its PBM (see Section 2.9.10), to identify members for MCO case management services as appropriate. In particular, the CONTRACTOR shall track utilization data to determine when a member has exceeded the ED threshold (see Section 2.14.1.13).

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  2.9.6.1   General
 
  2.9.6.1.1   The CONTRACTOR shall provide care coordination to all persons enrolled in TennCare CHOICES in accordance with this Agreement and to other TennCare members only in order to determine the member’s eligibility for and facilitate the member’s enrollment in TennCare CHOICES. Except for the initial process for current members that is necessary to determine the member’s eligibility for and facilitate the member’s enrollment in TennCare CHOICES, care coordination shall not be available to non-CHOICES members.
 
  2.9.6.1.2   The CONTRACTOR shall provide care coordination in a comprehensive, holistic, person-centered manner.
 
  2.9.6.1.3   The CONTRACTOR shall use care coordination as the continuous process of: (1) assessing a member’s physical, behavioral, functional, and psychosocial needs; (2) identifying the physical health, behavioral health and long-term care services and other social support services and assistance (e.g., housing or income assistance) that are necessary to meet identified needs; (3) ensuring timely access to and provision, coordination and monitoring of physical health, behavioral health, and long-term care services needed to help the member maintain or improve his or her physical or behavioral health status or functional abilities and maximize independence; and (4) facilitating access to other social support services and assistance needed in order to ensure the member’s health, safety and welfare, and as applicable, to delay or prevent the need for more expensive institutional placement.
 
  2.9.6.1.4   Long-term care services identified through care coordination and provided by the CONTRACTOR shall build upon and not supplant a member’s existing support system, including but not limited to informal supports provided by family and other caregivers, services that may be available at no cost to the member through other entities, and services that are reimbursable through other public or private funding sources, such as Medicare or long-term care insurance.
 
  2.9.6.1.5   The CONTRACTOR shall develop and implement policies and procedures for care coordination that comply with the requirements of this Agreement.
 
  2.9.6.1.6   The CONTRACTOR’s failure to meet requirements, including timelines, for care coordination set forth in this Agreement, except for good cause, constitutes noncompliance with this Agreement. Such failure shall not affect any determination of eligibility for CHOICES enrollment, which shall be based only on whether the member meets CHOICES eligibility and enrollment criteria, as defined pursuant to the Section 1115 TennCare Demonstration Waiver, federal and state laws and regulations, this Agreement, and TennCare policies and protocols. Nor shall such failure affect any determination of coverage for CHOICES benefits which shall be based only on the covered benefits for the applicable CHOICES group in which the member is enrolled as defined pursuant to the Section 1115 TennCare Demonstration Waiver, federal and state laws and regulations, this Agreement, and TennCare policies and protocols; and in accordance with requirements pertaining to medical necessity.

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  2.9.6.1.7   The CONTRACTOR shall ensure that its care coordination program complies with 42 CFR 438.208.
 
  2.9.6.1.8   The CONTRACTOR shall ensure that, upon enrollment into CHOICES, MCO case management and/or disease management activities are integrated with CHOICES care coordination processes and functions, and that the member’s assigned care coordinator has primary responsibility for coordination of all the member’s physical health, behavioral health, and long-term care needs, including appropriate management of conditions specified in 2.8.1.1. The care coordinator may use resources and staff from the CONTRACTOR’s case management and disease management programs, including persons with specialized expertise in areas such as behavioral health, to supplement but not supplant the role and responsibilities of the care coordinator/care coordination team.
 
  2.9.6.2   Intake Process for Members New to Both TennCare and CHOICES
 
  2.9.6.2.1   The CONTRACTOR shall refer all inquiries regarding CHOICES enrollment by or on behalf of individuals who are not enrolled with the CONTRACTOR to TENNCARE or its designee. The form and format for such referrals shall be developed in collaboration with the CONTRACTOR and TENNCARE or its designee.
 
  2.9.6.2.2   TENNCARE or its designee will assist individuals who are not enrolled in TennCare with TennCare eligibility and CHOICES enrollment.
 
  2.9.6.2.3   Functions of the Single Point of Entry (SPOE)
 
  2.9.6.2.3.1   For persons wishing to apply for CHOICES, TENNCARE or its designee may employ a screening process, using the tool and protocols specified by TENNCARE, to assist with intake for persons new to both TennCare and CHOICES. Such screening process shall assess: (1) whether the applicant appears to meet categorical and financial eligibility criteria for CHOICES; (2) whether the applicant appears to meet nursing facility level of care; and (3) for applicants seeking access to HCBS through enrollment in CHOICES Group 2, whether it appears that the applicant’s needs can be safely and effectively met in the community and at a cost that does not exceed nursing facility care.
 
  2.9.6.2.3.2   For persons identified by TENNCARE or its designee as meeting the screening criteria, or for whom TENNCARE or its designee opts not to use a screening process, TENNCARE or its designee will conduct a face-to-face intake visit with the applicant. As part of this intake visit TENNCARE or its designee will, using the tools and protocols specified by TENNCARE, conduct a level of care and needs assessment; assess the member’s existing natural support system, including but not limited to informal supports provided by family and other caregivers, services that may be available at no cost to the member through other entities, and services that are reimbursable through other public or private funding sources, such as Medicare or long-term care insurance; and identify the long-term care services and home health and/or private duty nursing services that may be needed by the applicant upon enrollment into CHOICES that would build upon and not supplant a member’s existing natural support system.

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  2.9.6.2.3.3   TENNCARE or its designee shall conduct the intake visit, including the level of care and needs assessment, in the applicant’s place of residence, except under extenuating circumstances (such as the member’s hospitalization), which shall be documented in writing.
 
  2.9.6.2.3.4   As part of the intake visit, TENNCARE or its designee shall: (1) provide general CHOICES education and information, as specified by TENNCARE, and assist in answering any questions the applicant may have; (2) provide information about estate recovery; (3) provide choice counseling and facilitate the selection of an MCO by the applicant or his/her representative; (4) provide information regarding freedom of choice of nursing facility versus HCBS, both verbally and in writing, and obtain a Freedom of Choice form signed by the applicant or his/her representative; (5) for applicants who want to receive NF services (a) provide detailed information and signed acknowledgement of understanding regarding a CHOICES member’s responsibility with respect to payment of patient liability amounts, including, as applicable, the potential consequences for non-payment of patient liability which may include loss of the member’s current nursing facility provider, disenrollment from CHOICES, and to the extent the member’s eligibility is dependent on receipt of long-term care services, possible loss of eligibility for TennCare; and (b) provide information regarding the completion of all PASRR requirements prior to nursing facility admission; (6) for applicants who are seeking HCBS: (a) conduct a risk assessment using a tool and protocol specified by TENNCARE and develop, as applicable, a risk agreement that shall be signed by the applicant or his/her representative and which shall include identified risks to the applicant, the consequences of such risks, strategies to mitigate the identified risks, and the applicant’s decision regarding his/her acceptance of risk; (b) make a determination regarding whether the applicant’s needs can be safely and effectively met in the community and at a cost that does not exceed nursing facility care, including explanation to the applicant regarding the individual cost neutrality cap, and notification to and signed acknowledgement of understanding by the applicant or his/her representative that a change in a member’s needs or circumstances that would result in the cost neutrality cap being exceeded or that would result in the MCO’s inability to safely and effectively meet a member’s needs in the community and within the cost neutrality cap may result in the member’s disenrollment from CHOICES Group 2, in which case, the care coordinator will assist with transition to a more appropriate care delivery setting; and (c) provide information regarding consumer direction and obtain signed documentation of the applicant’s interest in participating in consumer direction; and (7) provide information regarding next steps in the process including the need for approval by TENNCARE to enroll in CHOICES and the functions of the CONTRACTOR, including that the CONTRACTOR will develop and approve a plan of care.
 
  2.9.6.2.3.5   The listing of HCBS and home health and/or private duty nursing services the member may need shall be used by TENNCARE or its designee to determine whether services can be provided within the member’s cost neutrality cap and may be further refined based on the CONTRACTOR’s comprehensive needs assessment and plan of care development processes.

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  2.9.6.2.3.6   The State will be responsible for determining TennCare categorical and financial eligibility and level of care and enrolling eligible TennCare members into CHOICES.
 
  2.9.6.2.3.7   TENNCARE will notify the CONTRACTOR via the 834 eligibility file when a person has been enrolled in CHOICES and the member’s CHOICES Group. For members in CHOICES Group 2, TENNCARE will notify the CONTRACTOR of the member’s cost neutrality cap (see definition in Section 1 and see Section 2.6.1.5.2.3). For members in CHOICES Group 1, TENNCARE will notify the CONTRACTOR of applicable patient liability amounts (see Section 2.6.7.2).
 
  2.9.6.2.3.8   TENNCARE or its designee will make available to the CONTRACTOR the documentation from the intake visit, including but not limited to the member’s level of care and needs assessment, the assessment of the member’s existing natural support system, the member’s risk assessment and signed risk agreement (for members in CHOICES Group 2), and the services identified by TENNCARE or its designee.
 
  2.9.6.2.4   Functions of the CONTRACTOR for Members in CHOICES Group 1
 
  2.9.6.2.4.1   For members enrolled in CHOICES Group 1, who are, upon CHOICES enrollment, receiving nursing facility services, the CONTRACTOR shall immediately authorize such services in accordance with the level of nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12). Authorization for such services shall be from the current provider as of the effective date of CHOICES enrollment. The CONTRACTOR shall not move members enrolled in CHOICES Group 1 who are, upon CHOICES enrollment, receiving nursing facility services, to another facility unless: (1) the member or his/her representative specifically requests to move, which shall be documented in the member’s file; (2) the member or his/her representative provides written consent to move based on quality or other concerns raised by the CONTRACTOR, which shall not include the nursing facility‘s rate of reimbursement; or (3) the facility where the member is residing is not a contract provider. If the nursing facility is a non-contract provider, the CONTRACTOR shall (a) authorize continuation of the services pending enrollment of the facility as a contract provider (except a facility excluded for a 2-year period when the facility has withdrawn from Medicaid participation); (b) authorize continuation of the services pending facilitation of the member’s transition to a contract facility, subject to the member’s agreement with such transition; or (c) may continue to reimburse services from the non-contract nursing facility in accordance with TennCare rules and regulations.
 
  2.9.6.2.4.2   For members in CHOICES Group 1 who are receiving services in a nursing facility at the time of enrollment in CHOICES and have received such services for ninety (90) days or more, the CONTRACTOR shall, within sixty (60) calendar days of notice of the member’s enrollment in CHOICES, conduct a face-to-face visit with the member and perform any additional needs assessment deemed necessary by the CONTRACTOR (see Section 2.9.6.5.1). The care coordinator shall review the plan of care developed by the nursing facility and may supplement the plan of care as necessary and appropriate (see Section 2.9.6.6.1).

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  2.9.6.2.4.3   The care coordinator shall, for members in CHOICES Group 1 who are receiving services in a nursing facility at the time of enrollment in CHOICES and are new admissions to a nursing facility, having resided in the nursing facility for less than ninety (90) days, within thirty (30) calendar days of notice of the member’s enrollment in CHOICES conduct a face-to-face visit with the member and perform any additional needs assessment deemed necessary by the CONTRACTOR (see Section 2.9.6.5.1). The care coordinator shall review the plan of care developed by the nursing facility and may supplement the plan of care as necessary and appropriate (see in Section 2.9.6.6.1).
 
  2.9.6.2.4.4   For members in CHOICES Group 1 who are waiting for placement in a nursing facility, within ten (10) calendar days of notice of the member’s enrollment in CHOICES (1) the member’s care coordinator shall conduct a face-to-face visit with the member, which shall include (a) member education regarding choice of contract nursing facility providers, subject to the provider’s availability and willingness to timely delivery services, and obtain signed confirmation of the member’s choice of nursing facility; and (b) performing any additional needs assessment deemed necessary by the CONTRACTOR (see Section 2.9.6.5.1); and (2) the CONTRACTOR shall authorize and initiate nursing facility services. Upon admission to a nursing facility, the care coordinator shall participate as appropriate in the nursing facility’s care planning process (see Section 2.9.6.6.1.2) and may supplement the plan of care as necessary (see Section 2.9.6.6. 1. 1).
 
  2.9.6.2.4.5   The CONTRACTOR shall not divert or transition members in Group 1 to HCBS unless the member chooses to receive HCBS as an alternative to nursing facility and is enrolled in Group 2 or 3.
 
  2.9.6.2.4.6   The CONTRACTOR shall ensure that all PASRR requirements are met prior to a member’s admission to a nursing facility.
 
  2.9.6.2.4.7   For purposes of the CHOICES program, service authorization for nursing facility services shall be for the level of nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12) and shall include the duration of nursing facilities services to be provided; the requested start date; and other relevant information as prescribed by TENNCARE. The CONTRACTOR shall be responsible for confirming the nursing facility’s capacity and commitment to initiate services as authorized on or before the requested start date, and if the nursing facility is unable to initiate services as authorized on or before the requested start date, for arranging an alternative nursing facility that is able to initiate services as authorized on or before the requested start date in accordance with Section 2.9.6.2.4.8.
 
  2.9.6.2.4.8   If the CONTRACTOR is unable to place a member in the nursing facility requested by the member, the care coordinator shall meet with the member and his/her representative to discuss the reasons why the member cannot be placed with the requested nursing facility and the available options and identify an alternative nursing facility.

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  2.9.6.2.4.9   If the CONTRACTOR is unable to initiate any nursing facility service(s) in accordance with the timeframes specified in Section 2.9.6.2.4.1, the CONTRACTOR shall issue written notice to the member, documenting that the service will be delayed, the reasons for the delay, and the date the service will start, and shall make good faith efforts to ensure that services are provided as soon as practical.
 
  2.9.6.2.4.10   For CHOICES members approved by TENNCARE for Level II (or skilled) nursing facility services, the CONTRACTOR shall be responsible for monitoring the member’s continued need for Medicaid reimbursed skilled and/or rehabilitation services, promptly notifying TENNCARE when Level II nursing facility services are no longer medically necessary, and for the submission of information needed by TENNCARE to reevaluate the member’s level of care for nursing facility services (see also Section 2.14.1.12.2).
 
  2.9.6.2.5   Functions of the CONTRACTOR for Members in CHOICES Groups 2 and 3
 
  2.9.6.2.5.1   For members enrolled in CHOICES Group 2 who are, upon CHOICES enrollment, receiving community-based residential alternative services, the CONTRACTOR shall, immediately upon notice of the member’s enrollment in CHOICES, authorize such services from the current provider as of the effective date of CHOICES enrollment. In the case of those members enrolled in CHOICES Group 2 on the basis of Immediate Eligibility, community-based residential alternative services shall be authorized immediately upon notice of the member’s categorical and financial eligibility for TennCare CHOICES as of the effective date of CHOICES enrollment. The CONTRACTOR shall not transition members enrolled in CHOICES Group 2 who are, upon CHOICES enrollment, receiving services in a community-based residential alternative setting to another facility unless: (1) the member or his/her representative specifically requests to move, which shall be documented in the member’s file; (2) the member or his/her representative provides written consent to move based on quality or other concerns raised by the CONTRACTOR; or (3) the facility where the member is residing is not a contract provider; if the facility is a non-contract provider, the CONTRACTOR shall authorize medically necessary services from the noncontract provider for at least thirty (30) days which shall be extended as necessary to ensure continuity of care pending the facility’s enrollment with the CONTRACTOR or the member’s transition to a contract provider
 
  2.9.6.2.5.2   For members in CHOICES Group 2 who upon CHOICES enrollment are receiving services in a community-based residential alternative setting, within ten (10) calendar days of notice of the member’s enrollment in CHOICES the care coordinator shall conduct a face-to-face visit with the member, perform a comprehensive needs assessment (see Section 2.9.6.5), develop a plan of care (see Section 2.9.6.6), and authorize and initiate additional HCBS specified in the plan of care (i.e., assistive technology), except in the case of members enrolled on the basis of Immediate Eligibility. If a member residing in a community-based residential alternative setting is enrolled on the basis of Immediate Eligibility, the CONTRACTOR shall, upon notice that the State has determined that the member meets categorical and financial eligibility for TennCare CHOICES, immediately authorize community-based residential services and shall authorize and initiate additional HCBS specified in the member’s plan of care (i.e., assistive

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      technology) within five (5) days of notice; authorization for community-based residential alternative services shall be retroactive to the member’s effective date of CHOICES enrollment.
 
  2.9.6.2.5.3   The care coordinator shall, for all other CHOICES members in Groups 2 and 3 not specified in 2.9.6.2.5.1 — 2.9.6.2.5.2 above, within ten (10) calendar days of notice of the member’s enrollment in CHOICES, conduct a face-to-face visit with the member, perform a comprehensive needs assessment (see Section 2.9.6.5), develop a plan of care (see Section 2.9.6.6), and authorize and initiate HCBS, except in the case of members enrolled on the basis of Immediate Eligibility in which case only the limited package of HCBS shall be authorized and initiated. Members enrolled on the basis of Immediate Eligibility shall have access only to a limited package of HCBS (see Section 2.6.1.5.3) pending determination of categorical and financial eligibility for TennCare CHOICES; however all needed services shall be listed in the plan of care, and the CONTRACTOR shall immediately revise the service authorizations as necessary upon notice that the State has determined that the member meets categorical and financial eligibility for TennCare CHOICES and initiate services within five (5) days of notice.
 
  2.9.6.2.5.4   At the discretion of the CONTRACTOR, authorization of home health or private duty nursing services may be completed by the care coordinator or through the CONTRACTOR’s established UM processes but shall be in accordance with Section 2.9.2.1 of this Agreement, which requires the CONTRACTOR to continue providing medically necessary home health or private duty nursing services the member was receiving upon TennCare enrollment.
 
  2.9.6.2.5.5   The CONTRACTOR shall not admit a member enrolled in CHOICES Group 2 to a nursing facility unless: (1) the member requires a short-term nursing facility care stay; (2) the member chooses to transition to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR determines that it cannot safely and effectively meet the needs of the member and at a cost that is less than the member’s cost neutrality cap and the member agrees to transition to a nursing facility and enroll in Group 1.
 
  2.9.6.2.5.6   The CONTRACTOR shall not admit a member enrolled in CHOICES Group 3 to a nursing facility unless: (1) the member meets nursing facility level of care and is expected to require nursing facility services for ninety (90) days or less; or (2) the member meets nursing facility level of care, is expected to require nursing facility services for more than ninety (90) days and chooses to transition to a nursing facility and enroll in Group 1.
 
  2.9.6.2.5.7   In preparation for the face-to-face visit, the care coordinator shall review in-depth the information from the SPOE’s intake process (see Section 2.9.6.2.3), and the care coordinator shall consider that information, including the services identified by TENNCARE or its designee, when developing the member’s plan of care.
 
  2.9.6.2.5.8   As part of the face-to-face visit for members in CHOICES Group 2, the care coordinator shall review, and revise as necessary, the member’s risk assessment and risk agreement and have the member or his/her representative sign any revised risk agreement.

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  2.9.6.2.5.9   As part of the face-to-face visit, the care coordinator shall provide member education regarding choice of contract providers for HCBS, subject to the provider’s availability and willingness to timely deliver services, and obtain signed confirmation of the member’s choice of contract providers.
 
  2.9.6.2.5.10   For purposes of the CHOICES program, service authorizations shall include the amount, frequency, and duration of each service to be provided and the schedule at which such care is needed, as applicable; the requested start date; and other relevant information as prescribed by TENNCARE. The CONTRACTOR shall be responsible for confirming the provider’s capacity and commitment to initiate services as authorized on or before the requested start date, and if the provider is unable to initiate services as authorized on or before the requested start date, for arranging an alternative provider who is able to initiate services as authorized on or before the requested start date.
 
  2.9.6.2.5.11   The member’s care coordinator/care coordination team shall provide at least verbal notification to the member prior to initiation of HCBS identified in the plan of care regarding any change in providers selected by the member for each HCBS, including the reason such change has been made.
 
  2.9.6.2.5.12   If the CONTRACTOR is unable to initiate any HCBS in accordance with the timeframes specified herein, the CONTRACTOR shall issue written notice to the member, documenting the service(s) that will be delayed, the reasons for the delay, and the date the service(s) will start, and shall make good faith efforts to ensure that services are provided as soon as practical.
 
  2.9.6.2.5.13   TENNCARE may establish, pursuant to policies and protocols for management of waiting lists, alternative timeframes for completion of specified intake functions and activities when there is a waiting list, which may include at the time of CHOICES implementation.
  2.9.6.3   CHOICES Intake Process for the CONTRACTOR’s Current Members
 
  2.9.6.3.1   The CONTRACTOR shall develop and implement policies and procedures for ongoing identification of members who may be eligible for CHOICES. The CONTRACTOR shall use the following, at a minimum, to identify members who may be eligible for CHOICES:
 
  2.9.6.3.1.1   Referral from member’s PCP, specialist or other provider or other referral source;
 
  2.9.6.3.1.2   Self-referral by member or referral by member’s family or guardian;
 
  2.9.6.3.1.3   Referral from CONTRACTOR’s staff including but not limited to DM, MCO case management, and UM staff;
 
  2.9.6.3.1.4   Notification of hospital admission (see Section 2.12.9.38); and
 
  2.9.6.3.1.5   Upon notice from TENNCARE but no more than one hundred eighty (180) days following implementation of CHOICES in the Grand Region covered by this Agreement, periodic review (at least quarterly) of:

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  2.9.6.3.1.5.1   Claims or encounter data;
 
  2.9.6.3.1.5.2   Hospital admission or discharge data;
 
  2.9.6.3.1.5.3   Pharmacy data; and
 
  2.9.6.3.1.5.4   Data collected through the DM and/or UM processes.
 
  2.9.6.3.1.5.5   The CONTRACTOR may define in its policies and procedures, other steps that will be taken to better assess if the members identified through means other than referral or notice of hospital admission will likely qualify for CHOICES, and may target its screening and intake efforts to a more targeted list of persons that are most likely to need and to qualify for CHOICES services.
 
  2.9.6.3.2   As part of its identification process for members who may be eligible for CHOICES, the CONTRACTOR may initiate a telephone screening process, using the tool and protocols specified by TENNCARE. Such screening process shall: (1) verify the member’s current eligibility category based on information provided by TENNCARE in the 834 eligibility file; for persons seeking access to HCBS through enrollment in CHOICES Groups 2 or 3, identify whether the member meets categorical eligibility requirements for enrollment in such group based on his/her current eligibility category, and if not, for persons seeking to enroll in CHOICES Group 2, whether the member appears to meet categorical and financial eligibility criteria for the Institutional (i.e., CHOICES 217-Like HCBS) category); (2) determine whether the member appears to meet level of care eligibility for CHOICES; and (3) for members seeking access to HCBS through enrollment in CHOICES Group 2, determine whether it appears that the member’s needs can be safely and effectively met in the community and at a cost that does not exceed nursing facility care. Such telephone screening shall be conducted at the time of the initial call by the CONTRACTOR unless the member requests that the screening be conducted at another time, which shall be documented in writing in the CHOICES intake record.
 
  2.9.6.3.3   For CHOICES referrals by or on behalf of a potential CHOICES member, regardless of referral source, if the CONTRACTOR opts to use a telephone screening process, the CONTRACTOR shall make every effort to conduct such screening process at the time of referral, unless the person making the referral is not able or not authorized by the member to assist with the screening process, in which case the CONTRACTOR shall complete the telephone screening process as expeditiously as possible.
 
  2.9.6.3.3.1   Documentation of at least three (3) attempts to contact the member by phone (which shall include at least one (1) attempt to contact the member at the number most recently reported by the member and at least one (1) attempt to contact the member at the number provided in the referral, if different), followed by a letter sent to the member’s most recently reported address that provides information about CHOICES and how to obtain a screening for CHOICES, shall constitute sufficient effort by the CONTRACTOR to assist a member who has been referred for CHOICES, regardless of referral source.
 
  2.9.6.3.4   For persons identified through notification of hospital admission, the CONTRACTOR shall work with the discharge planner to determine whether long-

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      term care services may be needed upon discharge, and if so, shall complete all applicable screening and/or intake processes immediately to facilitate timely transition to the most integrated and cost effective long-term care delivery setting appropriate for the member’s needs.
 
  2.9.6.3.5   For identification by the CONTRACTOR of a member who may be eligible for CHOICES by means other than referral or notice of hospital admission, if the CONTRACTOR opts to use a telephone screening process, the CONTRACTOR shall complete the telephone screening process as expeditiously as possible.
 
  2.9.6.3.5.1   Documentation of at least one (1) attempt to contact the member by phone at the number most recently reported by the member, followed by a letter sent to the member’s most recently reported address that provides information about CHOICES and how to obtain a screening for CHOICES shall constitute sufficient effort by the CONTRACTOR to assist a member that has been identified by the CONTRACTOR by means other than referral.
 
  2.9.6.3.6   If the CONTRACTOR uses a telephone screening process, the CONTRACTOR shall document all screenings conducted by telephone and their disposition, with a written record.
 
  2.9.6.3.7   If the member does not meet the telephone screening criteria, the CONTRACTOR shall notify the member verbally and in writing: (1) that he/she does not appear to meet the criteria for enrollment in CHOICES; (2) that he/she has the right to continue with the CHOICES intake process and, if determined not eligible, to receive notice of such denial, including the member’s due process right to appeal; and (3) how, if the member wishes to proceed with the CHOICES intake process, the member can submit a written request to proceed with the CHOICES intake process to the CONTRACTOR. In the event that a member does submit such written request, the CONTRACTOR shall conduct a face-to-face intake visit, including level of care assessment and needs assessment, within five (5) business days of receipt of the member’s written request.
 
  2.9.6.3.8   If, through the screening process described above, or upon other identification by the CONTRACTOR of a member who appears to be eligible for CHOICES for whom the CONTRACTOR opts not to use such screening process, the care coordinator shall conduct a face-to-face intake visit with the member that includes a level of care assessment and a needs assessment (see Section 2.9.6.5) using tool(s) prior approved by TENNCARE and in accordance with the protocols specified by TENNCARE. The CONTRACTOR shall complete the telephone screening process and the face-to-face intake visit with the member within six (6) business days of receipt of the referral.
 
  2.9.6.3.8.1   For members in a nursing facility or seeking nursing facility services, the care coordinator shall perform any additional needs assessment deemed necessary by the CONTRACTOR (see Section 2.9.6.5.1).
 
  2.9.6.3.8.2   For members seeking HCBS, the care coordinator shall, using the tools and protocols specified by TENNCARE, assess the member’s existing natural support system, including but not limited to informal supports provided by family and other caregivers, services that may be available at no cost to the member through other entities, and services that are reimbursable through other public or private funding sources, such as Medicare or long-term care insurance; and identify the long-term care services and home health and/or private duty nursing

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      services that may be needed by the member upon enrollment into CHOICES that would build upon and not supplant a member’s existing natural support system.
 
  2.9.6.3.9   As part of the face-to-face intake visit, the care coordinator/care coordination team shall: (1) provide general CHOICES education and information, as specified by TENNCARE, to the member and assist in answering questions the member may have; (2) provide information about estate recovery; (3) provide assistance, as necessary, in facilitating gathering of categorical/financial documentation needed by DHS; (4) provide information regarding freedom of choice of nursing facility versus HCBS, both verbally and in writing, and obtain a Freedom of Choice form signed by the member or his/her representative; (5) for members who want to receive nursing facility services, (a) provide detailed information and signed acknowledgement of understanding regarding a CHOICES member’s responsibility with respect to payment of patient liability amounts, including the potential consequences for nonpayment of patient liability which may include loss of the member’s current nursing facility provider, disenrollment from CHOICES, and to the extent the member’s eligibility is dependent on receipt of long-term care services, possible loss of eligibility for TennCare; and (b) provide information regarding the completion of all PASRR requirements prior to nursing facility admission; (6) for members who are seeking HCBS, the care coordinator, shall: (a) conduct a risk assessment using a tool and protocol specified by TENNCARE and shall develop, as applicable, a risk agreement that shall be signed by the member or his/her representative and which shall include identified risks to the member, the consequences of such risks, strategies to mitigate the identified risks, and the member’s decision regarding his/her acceptance of risk; (b) make a determination regarding whether the person’s needs can be safely and effectively met in the community and at a cost that does not exceed nursing facility care, including explanation to the member regarding the individual cost neutrality cap, and notification to and signed acknowledgement of understanding by the member or his/her representative that a change in needs or circumstances that would result in the cost neutrality cap being exceeded or that would result in the CONTRACTOR’s inability to safely and effectively meet the member’s needs in the community and within the cost neutrality cap may result in the member’s disenrollment from CHOICES Group 2, in which case, the member’s care coordinator will assist with transition to a more appropriate care delivery setting; and (c) provide information regarding consumer direction and obtain written confirmation of the member’s decision regarding participation in consumer direction; and (7) for all members, provide information regarding choice of contract providers, subject to the provider’s availability and willingness to timely deliver services, and obtain signed documentation of the member’s choice of contract providers.
 
  2.9.6.3.10   For CHOICES referrals by or on behalf of a potential CHOICES member, regardless of referral source, the care coordinator shall conduct the face-to-face intake visit and shall develop a plan of care, as appropriate (see Section 2.9.6.6), within six (6) business days of receipt of such referral, unless a later date is requested by the member, which shall be documented in writing in the CHOICES intake record.
 
  2.9.6.3.11   For members identified by the CONTRACTOR as potentially eligible for CHOICES by means other than referral, the care coordinator shall conduct the face-to-face intake visit and shall develop a plan of care, as appropriate (see Section 2.9.6.6),

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      within thirty (30) days of identification of the member as potentially eligible for CHOICES. For persons identified through notification of hospital admission, the CONTRACTOR shall coordinate with the hospital discharge planner to determine whether long-term care services may be needed upon discharge, and if so, complete all applicable screening and/or intake processes immediately to facilitate timely transition to the most integrated and cost effective long-term care delivery setting appropriate for the member’s needs.
 
  2.9.6.3.12   Once completed, the CONTRACTOR shall submit the level of care and, for members requesting HCBS, documentation, as specified by TENNCARE, to verify that the member’s needs can be safely and effectively met in the community and within the cost neutrality cap to TENNCARE within one (1) business day.
 
  2.9.6.3.13   If the member is seeking access to HCBS through enrollment in CHOICES Group 2 and the enrollment target for CHOICES Group 2 has been reached, the CONTRACTOR shall notify TENNCARE, at the time of submission of the level of care and needs assessment and plan of care, as appropriate, whether the person shall be placed on a waiting list for CHOICES Group 2. If the CONTRACTOR wishes to enroll the person in CHOICES Group 2 as a cost effective alternative (CEA) to nursing facility care that would otherwise be provided, the CONTRACTOR shall submit to TENNCARE the following:
 
  2.9.6.3.13.1   A written summary of the CONTRACTOR’s CEA determination, including and explanation of the member’s circumstances which warrant the immediate provision of nursing facility services unless HCBS are immediately available.
 
  2.9.6.3.13.2   TENNCARE may request additional information as needed to confirm the CONTRACTOR’s CEA determination and/or provider capacity to meet the member’s needs, and shall, only upon receipt of satisfactory documentation, enroll the member in CHOICES.
 
  2.9.6.3.14   The CONTRACTOR shall be responsible for (1) advising members who appear to meet the nursing facility level of care that are seeking access to HCBS through enrollment in CHOICES Group 2 when an enrollment target has been (or will soon be) reached; (2) advising such persons that they may choose to receive nursing facility services if HCBS are not immediately available; (3) determining whether the person wants nursing facility services if HCBS are not immediately available; and (4) at the CONTRACTOR’s sole discretion, making a determination regarding whether enrollment in Group 2 constitutes a CEA because the immediate provision of nursing facility services will otherwise be required.
 
  2.9.6.3.15   The State will be responsible for determining TennCare categorical and financial eligibility and level of care and enrolling eligible TennCare members into CHOICES.
 
  2.9.6.3.16   TENNCARE will notify the CONTRACTOR via the 834 eligibility file when a person has been enrolled in CHOICES and, if the member is enrolled in CHOICES, the member’s CHOICES Group. For members in CHOICES Group 2, TENNCARE will notify the CONTRACTOR of the member’s cost neutrality cap (see definition in Section 1 and see Section 2.6.1.5.2.3). For members in CHOICES Group 1, TENNCARE will notify the CONTRACTOR of applicable patient liability amounts (see Section 2.6.7.2).

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  2.9.6.3.17   The CONTRACTOR shall, within five (5) calendar days of notice of the member’s enrollment in CHOICES, authorize and initiate long-term care services.
 
  2.9.6.3.17.1   For purposes of the CHOICES program, service authorizations shall include the amount, frequency, and duration of each service to be provided, and the schedule at which such care is needed, as applicable; and other relevant information as prescribed by TENNCARE. The CONTRACTOR is responsible for confirming the provider’s capacity and commitment to initiate services as authorized on or before the requested start date, and if the provider is unable to initiate services as authorized on or before the requested start date, shall select an alternative provider who is able to initiate services as authorized on or before the requested start date.
 
  2.9.6.3.17.2   The CONTRACTOR shall provide at least verbal notice to the member prior to initiation of HCBS identified in the plan of care regarding any change in providers selected by the member for each HCBS; including the reason such change has been made. If the CONTRACTOR is unable to place a member in the nursing facility or community-based residential alternative setting requested by the member, the care coordinator shall meet with the member and his/her representative to discuss the reasons why the member cannot be placed with the requested facility and the available options and identify an alternative facility.
 
  2.9.6.3.17.3   If the CONTRACTOR is unable to initiate any long-term care service within the timeframes specified in this Agreement, the CONTRACTOR shall issue written notice to the member, documenting the service(s) that will be delayed, the reasons for the delay and the date the service(s) will start, and shall make good faith efforts to ensure that services are provided as soon as practical.
 
  2.9.6.3.17.4   For members enrolled in CHOICES Groups 1 or 2 who are, upon CHOICES enrollment, receiving nursing facility or community-based residential alternative services from a contract provider, the CONTRACTOR shall authorize such services from the current provider as of the effective date of CHOICES enrollment. The CONTRACTOR shall not move members enrolled in CHOICES Groups 1 or 2 who are, upon CHOICES enrollment, receiving services in a nursing facility or community-based residential alternative setting to another facility unless: (1) the member or his/her representative specifically requests to move, which shall be documented in the member’s file; (2) the member or his/her representative provides written consent to move based on quality or other concerns raised by the CONTRACTOR, which shall not include the nursing facility’s rate of reimbursement; or (3) the facility where the member is residing is not a contract provider; if the community-based residential facility where the member is currently residing is not a contract provider, the CONTRACTOR shall provide continuation of services in such facility for at least thirty (30) days, which shall be extended as necessary to ensure continuity of care pending the facility’s contracting with the CONTRACTOR or the member’s transition to a contract facility; if the member is transitioned to a contract facility, the CONTRACTOR shall facilitate a seamless transition to the new facility; if the nursing facility where the member is currently residing is a non-contract provider, the CONTRACTOR shall (a) authorize continuation of the services pending enrollment of the facility as a contract provider (except a

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      facility excluded for a 2-year period when the facility has withdrawn from Medicaid participation); (b) authorize continuation of the services pending facilitation of the member’s transition to a contract facility, subject to the member’s agreement with such transition; or (c) may continue to reimburse services from the non-contract nursing facility in accordance with TennCare rules and regulations.
 
  2.9.6.3.17.5   For members receiving nursing facility services, the care coordinator shall participate as appropriate in the nursing facility’s care planning process (see Section 2.9.6.5.1) and may supplement the plan of care as necessary (see Section 2.9.6.6.1).
 
  2.9.6.3.17.6   The CONTRACTOR shall not divert or transition members in CHOICES Group 1 to HCBS unless the member chooses to receive HCBS as an alternative to nursing facility and is enrolled in Group 2 or 3.
 
  2.9.6.3.17.7   The CONTRACTOR shall ensure that all PASRR requirements are met prior to a member’s admission to a nursing facility.
 
  2.9.6.3.17.8   The CONTRACTOR shall not admit a member enrolled in CHOICES Group 2 to a nursing facility unless: (1) the member requires a short-term nursing facility care stay; (2) the member chooses to transition to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR determines that it cannot safely and effectively meet the needs of the member and at a cost that is less than the member’s cost neutrality cap and the member agrees to transition to a nursing facility and enroll in Group 1.
 
  2.9.6.3.17.9   The CONTRACTOR shall not admit a member enrolled in CHOICES Group 3 to a nursing facility unless: (1) the member meets nursing facility level of care and is expected to require nursing facility services for ninety (90) days or less; or (2) the member meets nursing facility level of care, is expected to require nursing facility services for more than ninety (90) days and chooses to transition to a nursing facility and enroll in Group 1.
 
  2.9.6.3.18   TENNCARE may establish, pursuant to policies and protocols for management of waiting lists, alternative timeframes for completion of specified intake functions and activities for persons when there is a waiting list, which may include at the time of CHOICES implementation.
 
  2.9.6.4   Care Coordination upon Enrollment in CHOICES
 
  2.9.6.4.1   Upon notice of a member’s enrollment in CHOICES, the CONTRACTOR shall assume responsibility for all care coordination functions and activities described herein (assessment and care planning activities for members currently enrolled with the CONTRACTOR shall begin prior to CHOICES enrollment; see Section 2.9.6.3).
 
  2.9.6.4.2   The CONTRACTOR shall be responsible for all aspects of care coordination and all requirements pertaining thereto, including but not limited to requirements set forth in the Section 1115 TennCare Demonstration Waiver, federal and state laws and regulations, this Agreement, and TENNCARE policies and protocols.

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  2.9.6.4.3   The CONTRACTOR shall assign to each member a specific care coordinator who shall have primary responsibility for performance of care coordination activities as specified in this Agreement, and who shall be the member’s point of contact for coordination of all physical health, behavioral health, and long-term care services.
 
  2.9.6.4.3.1   For CHOICES members, who are, upon CHOICES enrollment, receiving services in a nursing facility or a community-based residential alternative setting, the CONTRACTOR shall assign a specific care coordinator prior to the first face-to-face visit required in this Agreement. If the first face-to-face visit will not occur within the first ten (10) days of the member’s enrollment in CHOICES, the CONTRACTOR shall send the member written notification within ten (10) calendar days of the member’s enrollment that explains how the member can reach the care coordination unit for assistance with concerns or questions pending the assignment of a specific care coordinator.
 
  2.9.6.4.3.2   For CHOICES members who, upon enrollment in CHOICES, are not receiving services in a nursing facility or a community-based residential alternative setting, the CONTRACTOR shall assign a specific care coordinator and shall advise the member of the name of his/her care coordinator and provide contact information prior to the initiation of services (see Section 2.9.6.2.4.4 and 2.9.6.2.5.3), but no more than ten (10) calendar days following CHOICES enrollment.
 
  2.9.6.4.4   The CONTRACTOR may utilize a care coordination team approach to performing care coordination activities prescribed in Section 2.9.6. For each CHOICES member, the CONTRACTOR’s care coordination team shall consist of the member’s care coordinator and specific other persons with relevant expertise and experience appropriate to address the needs of CHOICES members. Care coordination teams shall be discrete entities within the CONTRACTOR’s organizational structure dedicated to fulfilling CHOICES care coordination functions. The CONTRACTOR shall establish policies and procedures that specify, at a minimum: the composition of care coordination teams; the tasks that will be performed directly by the care coordinator; measures taken to ensure that the care coordinator remains the member’s primary point of contact for the CHOICES program and related issues; escalation procedures to elevate issues to the care coordinator in a timely manner; and measures taken to ensure that if a member needs to reach his/her care coordinator specifically, calls that require immediate attention by a care coordinator are handled by a care coordinator and calls that do not require immediate attention are returned by the member’s care coordinator the next business day.

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  2.9.6.5   Needs Assessment
  2.9.6.5.1   For Members in CHOICES Group 1
 
  2.9.6.5.1.1   As part of the face-to-face intake visit for current members or face-to-face visit with new members in CHOICES Group 1, as applicable, a care coordinator shall conduct any needs assessment deemed necessary by the CONTRACTOR, using a tool prior approved by TENNCARE and in accordance with protocols specified by TENNCARE. The care coordinator shall assess the member’s potential for and interest in transition to the community and ensure coordination of the member’s physical health, behavioral health, and long-term care needs. This assessment may include identification of targeted strategies related to improving health, functional, or quality of life outcomes (e.g., related to disease management or pharmacy management) or to increasing and/or maintaining functional abilities, including services covered by the CONTRACTOR that are beyond the scope of the nursing facility services benefit.
 
  2.9.6.5.1.2   Needs reassessments shall be conducted as the care coordinator deems necessary.
 
  2.9.6.5.2   For Members in CHOICES Groups 2 and 3
 
  2.9.6.5.2.1   The care coordinator shall conduct a comprehensive needs assessment using a tool prior approved by TENNCARE and in accordance with protocols specified by TENNCARE as part of its face-to-face visit with new members in CHOICES Groups 2 and 3 (see Section 2.9.6.2.5) and as part of its face-to-face intake visit for current members applying for CHOICES Groups 2 and 3.
 
  2.9.6.5.2.2   At a minimum, for members in CHOICES Group 2 and 3, the comprehensive needs assessment shall assess: (1) the member’s physical, behavioral, functional, and psychosocial needs, including an evaluation of the member’s financial health as it relates to the member’s ability to maintain a safe and healthy living environment; (2) the member’s natural supports, including care being provided by family members and/or other caregivers, and long-term care services the member is currently receiving (regardless of payor), and whether there is any anticipated change in the member’s need for such care or services or the availability of such care or services from the current caregiver or payor; and (3) the physical health, behavioral health, and long-term care services and other social support services and assistance (e.g., housing or income assistance) that are needed, as applicable, to ensure the member’s health safety and welfare in the community and to delay or prevent the need for institutional placement.
 
  2.9.6.5.2.3   The comprehensive needs assessment shall be conducted at least annually and as the care coordinator deems necessary.
 
  2.9.6.5.2.4   For CHOICES Group 2 and 3 members, the CONTRACTOR shall visit the member face-to-face within five (5) business days of becoming aware that the member has a significant change in needs or circumstances as defined in Section 2.9.6.9.2.1.16 The care coordinator shall assess the member’s needs, conduct a comprehensive needs assessment and update the member’s plan of care as deemed necessary based on the member’s circumstances.

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  2.9.6.6   Plan of Care
  2.9.6.6.1   For Members in CHOICES Group 1
 
  2.9.6.6.1.1   For members in CHOICES Group 1, the member’s care coordinator/care coordination team may: (1) rely on the plan of care developed by the nursing facility for service delivery instead of developing a plan of care for the member; and (2) supplement the plan of care as necessary with the development and implementation of targeted strategies to improve health, functional, or quality of life outcomes (e.g., related to disease management or pharmacy management) or to increase and/or maintain functional abilities. A copy of any supplements to the nursing facility plan of care, and updates to such supplements, shall be maintained by the CONTRACTOR in the member’s file.
 
  2.9.6.6.1.2   The member’s care coordinator shall participate as appropriate in the nursing facility’s care planning process and advocate for the member.
 
  2.9.6.6.1.3   The member’s care coordinator/care coordination team shall be responsible for coordination of the member’s physical health, behavioral health, and long-term care needs, which shall include coordination with the nursing facility as necessary to facilitate access to physical health and/or behavioral health services needed by the member and to help ensure the proper management of the member’s acute and/or chronic physical health or behavioral health conditions, including services covered by the CONTRACTOR that are beyond the scope of the nursing facility services benefit.
 
  2.9.6.6.2   For Members in CHOICES Groups 2 and 3
 
  2.9.6.6.2.1   For members in CHOICES Groups 2 and 3, the care coordinator shall coordinate and facilitate a care planning team that includes, at a minimum, the member and the member’s care coordinator. As appropriate, the care coordinator shall include or seek input from other individuals such as the member’s representative or other persons authorized by the member to assist with needs assessment and care planning activities.
 
  2.9.6.6.2.2   The CONTRACTOR shall ensure that care coordinators consult with the member’s PCP, specialists, behavioral health providers, other providers, and interdisciplinary team experts, as needed when developing the plan of care.
 
  2.9.6.6.2.3   The care coordinator shall verify that the decisions made by the care planning team are documented in a written, comprehensive plan of care.
 
  2.9.6.6.2.4   The plan of care developed for CHOICES members in Groups 2 and 3 prior to initiation of HCBS shall at a minimum include: (1) pertinent demographic information regarding the member including the name and contact information of any representative and a list of other persons authorized by the member to have access to health care (including long-term care) related information and to assist with assessment, planning, and/or implementation of health care (including longterm care) related services and supports; (2) care, including specific tasks and functions, that will be performed by family members and other caregivers; (3) home health, private duty nursing, and long-term care services the member will

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      receive from other payor sources including the payor of such services; (4) home health and private duty nursing that will be authorized by the CONTRACTOR, except in the case of persons enrolled on the basis of Immediate Eligibility who shall have access to services beyond the limited package of HCBS (see Section 2.6.1.5.3) only upon determination of categorical and financial eligibility for TennCare; (5) HCBS that will be authorized by the CONTRACTOR, including the amount, frequency, duration, and scope (tasks and functions to be performed) of each service to be provided, and the schedule at which such care is needed, as applicable; members enrolled on the basis of Immediate Eligibility shall have access only to a limited package of HCBS (see Section 2.6.1.5.3) pending determination of categorical and financial eligibility for TennCare CHOICES however all identified needed services shall be listed in the plan of care; (6) a detailed back-up plan for situations when regularly scheduled HCBS providers are unavailable or do not arrive as scheduled; the back-up plan may include paid and unpaid supports and shall include the names and telephone numbers of persons and agencies to contact and the services provided by listed contacts; the CONTRACTOR shall assess the adequacy of the back-up plan; and (7) for CHOICES Group 2 members, the projected TennCare monthly and annual cost of home health and private duty nursing identified in (4) above, and the projected monthly and annual cost of HCBS specified in (5) above, and for CHOICES Group 3 members, the projected total cost of HCBS specified in (5) above, excluding the cost of minor home modifications.
  2.9.6.6.2.5   Within thirty (30) calendar days of notice of enrollment in CHOICES, for members in CHOICES Groups 2 and 3 the plan of care shall include, at a minimum, the following additional elements:
 
  2.9.6.6.2.5.1   Description of the member’s current physical and behavioral health conditions and functional status (i.e., areas of functional deficit), and the member’s physical, behavioral and functional needs;
 
  2.9.6.6.2.5.2   Description of the member’s physical environment and any modifications necessary to ensure the member’s health and safety;
 
  2.9.6.6.2.5.3   Description of medical equipment used or needed by the member (if applicable);
 
  2.9.6.6.2.5.4   Description of any special communication needs including interpreters or special devices;
 
  2.9.6.6.2.5.5   A description of the member’s psychosocial needs, including any housing or financial assistance needs which could impact the member’s ability to maintain a safe and healthy living environment;
 
  2.9.6.6.2.5.6   Goals, objectives and desired health, functional, and quality of life outcomes for the member;
 
  2.9.6.6.2.5.7   Description of other services that will be provided to the member, including (1) covered physical and behavioral health services that will be provided by the CONTRACTOR to help the member maintain or improve his or her physical or behavioral health status or functional abilities and maximize independence; (2) other social support services and assistance needed in order to ensure the

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      member’s health, safety and welfare, and as applicable, to delay or prevent the need for more expensive institutional placement; and (3) any non-covered services including services provided by other community resources, including plans to link the member to financial assistance programs including but not limited to housing, utilities and food as needed;
 
  2.9.6.6.2.5.8   Relevant information from the member’s individualized treatment plan for any member receiving behavioral health services (see Section 2.7.2.1.4 of this Agreement) that is needed by a long-term care provider, caregiver or the care coordinator to ensure appropriate delivery of services or coordination of services;
 
  2.9.6.6.2.5.9   Relevant information regarding the member’s physical health condition(s), including treatment and medication regimen, that is needed by a long-term care provider, caregiver or the care coordinator to ensure appropriate delivery of services or coordination of care;
 
  2.9.6.6.2.5.10   Frequency of planned care coordinator contacts needed, which shall include consideration of the member’s individualized needs and circumstances, and which shall at minimum meet required contacts as specified in Section 2.9.6.9.4 (unplanned care coordinator contacts shall be provided as needed);
 
  2.9.6.6.2.5.11   Additional information for members who elect consumer direction of HCBS, including but not limited to whether the member requires a representative to participate in consumer direction and the specific services that will be consumer directed;
 
  2.9.6.6.2.5.12   If the member chooses to self-direct any health care tasks, the type of tasks that will be self-directed;
 
  2.9.6.6.2.5.13   Any steps the member and/or representative should take in the event of an emergency that differ from the standard emergency protocol;
 
  2.9.6.6.2.5.14   A disaster preparedness plan specific to the member; and
 
  2.9.6.6.2.5.15   The member’s TennCare eligibility end date.
 
  2.9.6.6.2.6   The member’s care coordinator/care coordination team shall ensure that the member reviews, signs and dates the plan of care as well as any updates.
 
  2.9.6.6.2.6.1   The CONTRACTOR shall develop policies and procedures that describe the measures taken by the CONTRACTOR to address instances when a member refuses to sign the plan of care. The policies and procedures shall include a specific escalation process (ultimately to TENNCARE) that includes a review of the reasons for the member’s refusal as well as actions taken to resolve any disagreements with the plan of care and shall involve the consumer advocate in helping to facilitate resolution.
 
  2.9.6.6.2.6.2   When the refusal to sign is due to a member’s request for additional services, including requests for a different type or an increased amount, frequency, scope, and/or duration of services than what is included in the plan of care, the CONTRACTOR shall, in the case of a new plan of care, authorize and initiate

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      services in accordance with the plan of care; and, in the case of an annual or revised plan of care, ensure continuation of at least the level of services in place at the time the annual or revised plan of care was developed until a resolution is reached, which may include resolution of a timely filed appeal, if applicable. The CONTRACTOR shall not use the member’s acceptance of services as a waiver of the member’s right to dispute the plan of care or as cause to stop the resolution process.
 
  2.9.6.6.2.6.3   When the refusal to sign is due to the inclusion of services that the member does not want to receive, either in totality or in the amount, frequency, scope or duration of services in the plan of care, the care coordinator shall modify the risk agreement to note this issue, the associated risks, and the measures to mitigate the risks. The risk agreement shall be signed and dated by the member or his/her representative and the care coordinator. In the event the care coordinator determines that the member’s needs cannot be safely and effectively met in the community without receiving these services, the CONTRACTOR may request that it no longer provide long-term care services to the member (see Section 2.6.1.5.8).
 
  2.9.6.6.2.7   The member’s care coordinator/care coordination team shall provide a copy of the member’s completed plan of care, including any updates, to the member, the member’s representative, as applicable, and the member’s community residential alternative provider, as applicable. The member’s care coordinator/care coordination team shall provide copies to other providers authorized to deliver care to the member upon request, and shall ensure that such providers who do not receive a copy of the plan of care are informed in writing of all relevant information needed to ensure the provision of quality care for the member and to help ensure the member’s health, safety, and welfare, including but not limited to the tasks and functions to be performed.
 
  2.9.6.6.2.8   Within five (5) business days of completing a reassessment of a member’s needs, the member’s care coordinator/care coordination team shall update the member’s plan of care as appropriate, and the CONTRACTOR shall authorize and initiate HCBS in the updated plan of care. The CONTRACTOR shall comply with requirements for service authorization in Section 2.9.6.2.5.10, change of provider in Section 2.9.6.2.5.11, and notice of service delay in Section 2.9.6.2.5.12.
 
  2.9.6.6.2.9   The member’s care coordinator shall inform each member of his/her eligibility end date and educate members regarding the importance of maintaining TennCare CHOICES eligibility, that eligibility must be redetermined at least once a year, and that members will be contacted by TENNCARE or its designee near the date a redetermination is needed to assist them with the process, e.g., collecting appropriate documentation and completing the necessary forms.
  2.9.6.7   Nursing Facility Diversion
  2.9.6.7.1   The CONTRACTOR shall develop and implement a nursing facility diversion process that complies with the requirements in this Section 2.9.6.7 and is prior approved in writing by TENNCARE. The diversion process shall not prohibit or delay a member’s access to nursing facility services when these services are medically necessary and requested by the member.

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  2.9.6.7.2   At a minimum the CONTRACTOR’s diversion process shall target the following groups for diversion activities:
 
  2.9.6.7.2.1   Members in CHOICES Group 1 who are waiting for placement in a nursing facility;
 
  2.9.6.7.2.2   CHOICES members residing in their own homes who have a negative change in circumstances and/or deterioration in health or functional status and who request nursing facility services;
 
  2.9.6.7.2.3   CHOICES members residing in adult care homes or other community-based residential alternative settings who have a negative change in circumstances and/or deterioration in health or functional status and who request nursing facility services;
 
  2.9.6.7.2.4   CHOICES and non-CHOICES members admitted to an inpatient hospital or inpatient rehabilitation who are not residents of a nursing facility; and
 
  2.9.6.7.2.5   CHOICES and non-CHOICES members who are placed short-term in a nursing facility regardless of payer source.
 
  2.9.6.7.3   The CONTRACTOR’s nursing facility diversion process shall be tailored to meet the needs of each group identified in Section 2.9.6.7.2 above.
 
  2.9.6.7.4   The CONTRACTOR’s nursing facility diversion process shall include a detailed description of how the CONTRACTOR will work with providers (including hospitals regarding notice of admission and discharge planning; see Sections 2.9.6.3.4 and 2.9.6.3.11) to ensure appropriate communication among providers and between providers and the CONTRACTOR, training for key CONTRACTOR and provider staff, early identification of members who may be candidates for diversion (both CHOICES and non-CHOICES members), and follow-up activities to help sustain community living.
 
  2.9.6.7.5   The CONTRACTOR’s nursing facility diversion process shall include specific timelines for each identified activity.
  2.9.6.8   Nursing Facility-to-Community Transition
  2.9.6.8.1   The CONTRACTOR shall develop and implement methods for identifying members who may have the ability and/or desire to transition from a nursing facility to the community. Such methods shall include, at a minimum:
 
  2.9.6.8.1.1   Starting on the date of implementation of CHOICES in the Grand Region covered by this Agreement, referrals, including but not limited to, treating physician, nursing facility, other providers, community-based organizations, family, and self-referrals;
 
  2.9.6.8.1.2   Starting on the date of implementation of CHOICES in the Grand Region covered by this Agreement, identification through the care coordination process,

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      including but not limited to: assessments, information gathered from nursing facility staff or participation in Grand Rounds (as defined in Section 1); and
 
  2.9.6.8.1.3   Upon notice from TENNCARE but no more than one hundred and twenty (120) days following the implementation of CHOICES in the Grand Region covered by this Agreement, review and analysis of members identified by TENNCARE based on Minimum Data Set (MDS) data from nursing facilities.
 
  2.9.6.8.2   For transition referrals by or on behalf of a nursing facility resident, regardless of referral source, the CONTRACTOR shall ensure that within fourteen (14) days of the referral the CONTRACTOR conducts an in-facility visit with the member to determine the member’s interest in and potential ability to transition to the community, and provide orientation and information to the member regarding transition activities. The member’s care coordinator/care coordination team shall document in the member’s case file that transition was discussed with the member and indicate the member’s wishes as well as the member’s potential for transition. The CONTRACTOR shall not require a member to transition when the member expresses a desire to continue receiving nursing facility services.
 
  2.9.6.8.3   For identification by the CONTRACTOR by means other than referral or the care coordination process of a member who may have the ability and/or desire to transition from a nursing facility to the community, the CONTRACTOR shall ensure that within ninety (90) days of such identification the CONTRACTOR conducts an in-facility visit with the member to determine whether or not the member is interested in and potential ability to pursue transition to the community. The member’s care coordinator/care coordination team shall document in the member’s case file that transition was discussed with the member and indicate the member’s wishes as well as the member’s potential for transition. The CONTRACTOR shall not require a member to transition when the member expresses a desire to continue receiving nursing facility services.
 
  2.9.6.8.4   If the member wishes to pursue transition to the community, within fourteen (14) days of the initial visit (see Sections 2.9.6.8.2 and 2.9.6.8.3 above) or within fourteen (14) days of identification through the care coordination process, the care coordinator shall conduct an in-facility assessment of the member’s ability and/or desire to transition using tools and protocols specified or prior approved in writing by TENNCARE. This assessment shall include the identification of any barriers to a safe transition.
 
  2.9.6.8.5   As part of the transition assessment, the care coordinator shall conduct a risk assessment using a tool and protocol specified by TENNCARE, discuss with the member the risk involved in transitioning to the community and shall begin to develop, as applicable, a risk agreement that shall be signed by the member or his/her representative and which shall include identified risks to the member, the consequences of such risks, strategies to mitigate the identified risks, and the member’s decision regarding his/her acceptance of risk as part of the plan of care. The risk agreement shall include the frequency and type of care coordinator contacts that exceed the minimum contacts required (see Section 2.9.6.9.4), to mitigate any additional risks associated with transition and shall address any special circumstances due to transition. The member’s care coordinator/care coordination team shall also make a determination regarding whether the member’s needs can be safely and

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      effectively met in the community and at a cost that does not exceed nursing facility care. The member’s care coordinator/care coordination team shall explain to the member the individual cost neutrality cap and notification process and obtain a signed acknowledgement of understanding by the member or his/her representative that a change in a member’s needs or circumstances that would result in the cost neutrality cap being exceeded or that would result in the CONTRACTOR’s inability to safely and effectively meet a member’s needs in the community and within the cost neutrality cap may result in the member’s disenrollment from CHOICES Group 2, in which case, the CONTRACTOR will assist with transition to a more appropriate care delivery setting.
 
  2.9.6.8.6   For those members whose transition assessment indicates that they are not candidates for transition to the community, the care coordinator shall notify them in accordance with the specified transition assessment protocol.
 
  2.9.6.8.7   For those members whose transition assessment indicates that they are candidates for transition to the community, the care coordinator shall facilitate the development of and complete a transition plan within fourteen (14) days of the member’s transition assessment.
 
  2.9.6.8.8   The care coordinator shall include other individuals such as the member’s family and/or caregiver in the transition planning process if the member requests and/or approves, and such persons are willing and able to participate.
 
  2.9.6.8.9   As part of transition planning, prior to the member’s physical move to the community, the care coordinator shall visit the residence where the member will live to conduct an on-site evaluation of the physical residence and meet with the member’s family or other caregiver who will be residing with the member (as appropriate). The care coordinator shall include in the transition plan activities and/or services needed to mitigate any perceived risks in the residence including but not limited to an increase in face-to-face visits beyond the minimum required contacts in Sections 2.9.6.8.18 and 2.9.6.8.17.
 
  2.9.6.8.10   The transition plan shall address all services necessary to safely transition the member to the community and include at a minimum member needs related to housing, transportation, availability of caregivers, and other transition needs and supports. The transition plan shall also identify any barriers to a safe transition and strategies to overcome those barriers.
 
  2.9.6.8.11   The CONTRACTOR shall approve the transition plan and authorize any covered or cost effective alternative services included in the plan within ten (10) business days of completion of the plan. The transition plan shall be fully implemented within ninety (90) days from approval of the transition plan, except under extenuating circumstances which must be documented in writing.
 
  2.9.6.8.12   The member’s care coordinator shall also complete a plan of care that meets all criteria described in Section 2.9.6.6 for members in CHOICES Groups 2 and 3 including but not limited to completing a comprehensive needs assessment, completing and signing the risk agreement and making a final determination of cost neutrality. The plan of care shall be authorized and initiated prior to the member’s transition to the community.

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  2.9.6.8.13   The CONTRACTOR shall not prohibit a member from transitioning to the community once the member has been counseled regarding risk. However, the CONTRACTOR may determine that the member’s needs cannot be safely and effectively met in the community and at a cost that does not exceed nursing facility care. In such case, the CONTRACTOR shall seek written review and approval from TENNCARE prior to denial of any member’s request to transition to the community. If TENNCARE approves the CONTRACTOR’s request, the CONTRACTOR shall notify the member in accordance with TennCare rules and regulations and the transition assessment protocol, and the member shall have the right to appeal the determination (see Section 2.19.3.12 of this Agreement).
 
  2.9.6.8.14   Once completed, the CONTRACTOR shall submit to TENNCARE documentation, as specified by TENNCARE to verify that the member’s needs can be safely and effectively met in the community and within the cost neutrality cap. Before transitioning a member the CONTRACTOR shall verify that the member has been approved for enrollment in CHOICES Group 2 effective as of the planned transition date.
 
  2.9.6.8.15   The member’s care coordinator shall monitor all aspects of the transition process and take immediate action to address any barriers that arise during transition.
 
  2.9.6.8.16   For members transitioning to a setting other than a community-based residential alternative setting, the care coordinator shall upon transition utilize the EVV system to monitor the initiation and daily provision of services in accordance with the member’s new plan of care, and shall take immediate action to resolve any service gaps (see definition in Section 1).
 
  2.9.6.8.17   For members who will live independently in the community or whose on-site visit during transition planning indicated an elevated risk, within the first twenty-four (24) hours, the care coordinator shall visit the member in his/her residence. During the initial ninety (90) day post-transition period, the care coordinator shall conduct monthly face-to-face in-home visits to ensure that the plan of care is being followed, that the plan of care continues to meet the member’s needs, and the member has successfully transitioned to the community.
 
  2.9.6.8.18   For members transitioning to a community-based residential alternative setting or who will live with a relative or other caregiver, within the first twenty-four (24) hours the care coordinator shall contact the member and within seven (7) days after the member has transitioned to the community, the care coordinator shall visit the member in his/her new residence. During the initial ninety (90) day post-transition period, the care coordinator shall (1) at a minimum, contact the member by telephone each month to ensure that the plan of care is being followed, that the plan of care continues to meet the member’s needs, and the member has successfully transitioned to the community; and (2) conduct additional face-to-face visits as necessary to address issues and/or concerns and to ensure that the member’s needs are met.
 
  2.9.6.8.19   The member’s care coordinator shall monitor hospitalizations and short-term nursing facility stays for members who transition to identify and address issues that may prevent the member’s long-term community placement.

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  2.9.6.8.20   The CONTRACTOR shall monitor hospitalizations and nursing facility re-admission for members who transition from a nursing facility to the community to identify issues and implement strategies to improve transition outcomes.
 
  2.9.6.8.21   The CONTRACTOR shall be permitted to coordinate or subcontract with local community-based organizations to assist in the identification, planning and facilitation processes related to nursing facility-to-community transitions.
 
  2.9.6.8.22   The CONTRACTOR shall develop and implement any necessary assessment tools, transition plan templates, protocols, or training necessary to ensure that issues that may hinder a member’s successful transition are identified and addressed. Any tool, template, or protocol must be prior approved in writing by TENNCARE.
  2.9.6.9   Ongoing Care Coordination
  2.9.6.9.1   For Members in CHOICES Group 1
 
  2.9.6.9.1.1   The CONTRACTOR shall provide for the following ongoing care coordination to CHOICES members in Group 1:
 
  2.9.6.9.1.1.1   Develop protocols and processes to work with nursing facilities to coordinate the provision of care. At minimum, a care coordinator assigned to a resident of the nursing facility shall participate in quarterly Grand Rounds (as defined in Section 1). At least two of the Grand Rounds per year shall be conducted on-site in the facility, and the Grand Rounds shall identify and address any member who has experienced a potential significant change in needs or circumstances (see Section 2.9.6.9.1.1.5) or about whom the nursing facility or MCO has expressed concerns;
 
  2.9.6.9.1.1.2   Develop and implement targeted strategies to improve health, functional, or quality of life outcomes, e.g., related to disease management or pharmacy management, or to increase and/or maintain functional abilities;
 
  2.9.6.9.1.1.3   Coordinate with the nursing facility as necessary to facilitate access to physical health and/or behavioral health services needed by the member and to help ensure the proper management of the member’s acute and/or chronic health conditions, including services covered by the CONTRACTOR that are beyond the scope of the nursing facility services benefit;
 
  2.9.6.9.1.1.4   Intervene and address issues as they arise regarding payment of patient liability amounts and assist in interventions to address untimely or non-payment of patient liability in order to avoid the consequences of non-payment; and
 
  2.9.6.9.1.1.5   At a minimum, the CONTRACTOR shall consider the following a potential significant change in needs or circumstances for CHOICES Group 1 members who are residing in a nursing facility and contact the nursing facility to determine if a visit and reassessment is needed:
 
  2.9.6.9.1.1.5.1   Pattern of recurring falls;
 
  2.9.6.9.1.1.5.2   Incident, injury or complaint;

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  2.9.6.9.1.1.5.3   Report of abuse or neglect;
 
  2.9.6.9.1.1.5.4   Frequent hospitalizations; or
 
  2.9.6.9.1.1.5.5   Prolonged or significant change in health and/or functional status.
  2.9.6.9.2   For Members in CHOICES Groups 2 and 3
  2.9.6.9.2.1   The CONTRACTOR shall provide for the following ongoing care coordination to CHOICES members in Groups 2 and 3:
 
  2.9.6.9.2.1.1   Coordinate a care planning team, developing a plan of care and updating the plan as needed;
 
  2.9.6.9.2.1.2   During the development of the member’s plan of care and as part of the annual updates, the care coordinator shall discuss with the member his/her interest in consumer direction of HCBS;
 
  2.9.6.9.2.1.3   During the development of the member’s plan of care, the care coordinator shall educate the member about his/her ability to use advance directives and document the member’s decision in the member’s file;
 
  2.9.6.9.2.1.4   Ensure the plan of care addresses the member’s desired outcomes, needs and preferences;
 
  2.9.6.9.2.1.5   For members in CHOICES Group 2, each time a member’s plan of care is updated to change the level or type of service, document in accordance with TENNCARE policy that the projected total cost of HCBS, home health care and private duty nursing is less than the member’s cost neutrality cap. The CONTRACTOR shall monitor utilization to identify members who may exceed the cost neutrality cap and to intervene as necessary to maintain the member’s community placement. The CONTRACTOR shall also educate members in CHOICES Group 2 about the cost neutrality cap and what will happen if the cap is met;
 
  2.9.6.9.2.1.6   For members in CHOICES Group 3, determine whether the cost of HCBS, excluding minor home modifications, will exceed the expenditure cap for CHOICES Group 3. The CONTRACTOR shall continuously monitor a member’s expenditures and work with the member when he/she is approaching the limit including identifying non-long term care services that will be provided when the limit has been met to prevent/delay the need for institutionalization. Each time the plan of care for a member in CHOICES Group 3 is updated, the CONTRACTOR shall educate the member about the expenditure cap;
 
  2.9.6.9.2.1.7   For new services in an updated plan of care, the care coordinator shall provide the member with information about potential providers for each HCBS that will be provided by the CONTRACTOR and assist members with any requests for information that will help the member in choosing a provider and, if applicable, in changing providers, subject to the provider’s capacity and willingness to provide service;

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  2.9.6.9.2.1.8   Upon the scheduled initiation of services identified in the plan of care, the member’s care coordinator/care coordination team shall begin monitoring to ensure that services have been initiated and continue to be provided as authorized. This shall include ongoing monitoring via electronic visit verification to ensure that services are provided in accordance with the member’s plan of care, including the amount, frequency, duration and scope of each service, in accordance with the member’s service schedule; and that services continue to meet the member’s needs;
 
  2.9.6.9.2.1.9   Identify and address service gaps, ensure that back-up plans are implemented and effectively working, and evaluate service gaps to determine their cause and to minimize gaps going forward. The CONTRACTOR shall describe in policies and procedures the process for identifying, responding to, and resolving service gaps in a timely manner;
 
  2.9.6.9.2.1.10   Identify changes to member’s risk, address those changes and update the member’s risk agreement as necessary;
 
  2.9.6.9.2.1.11   Reassess a member’s needs and update a member’s plan of care in accordance with requirements and timelines specified Sections 2.9.6.5 and 2.9.6.6;
 
  2.9.6.9.2.1.12   Maintain appropriate on-going communication with community and natural supports to monitor and support their ongoing participation in the member’s care;
 
  2.9.6.9.2.1.13   For services not covered by the CONTRACTOR, coordinate with community organizations that provide services that are important to the health, safety and well-being of members. This may include but shall not be limited to referrals to other agencies for assistance and assistance as needed with applying for programs, but the CONTRACTOR shall not be responsible for the provision or quality of non-covered services provided by other entities;
 
  2.9.6.9.2.1.14   Notify TENNCARE immediately, in the manner specified by TENNCARE, if the CONTRACTOR determines that the needs of a member in CHOICES Group 2 cannot be met safely in the community and within the member’s cost neutrality cap;
 
  2.9.6.9.2.1.15   Perform additional requirements for consumer direction of HCBS as specified in Section 2.9.6.10; and
 
  2.9.6.9.2.1.16   At a minimum, the CONTRACTOR shall consider the following a significant change in needs or circumstances for members in CHOICES Groups 2 and 3 residing in the community:
 
  2.9.6.9.2.1.16.1   Change of residence or primary caregiver or loss of essential social supports;
 
  2.9.6.9.2.1.16.2   Significant change in health and/or functional status;
 
  2.9.6.9.2.1.16.3   Loss of mobility;
 
  2.9.6.9.2.1.16.4   An event that significantly increases the perceived risk to a member; or

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  2.9.6.9.2.1.17   Identify and immediately respond to problems and issues including but not limited to circumstances that would impact the member’s ability to continue living in the community.
  2.9.6.9.3   For ALL CHOICES Members
  2.9.6.9.3.1   The CONTRACTOR shall provide for the following ongoing care coordination to all CHOICES members:
 
  2.9.6.9.3.1.1   Conduct a level of care reassessment at least annually and within five (5) business days of the CONTRACTOR’s becoming aware that the member’s functional or medical status has changed in a way that may affect level of care eligibility.
 
  2.9.6.9.3.1.1.1   If the level of care assessment indicates a change in the level of care or if the assessment was prompted by a request by a member, a member’s representative or caregiver or another entity for a change in level of services, the assessment shall be forwarded to TENNCARE for determination;
 
  2.9.6.9.3.1.1.2   If the level of care assessment indicates no change in level of care, the CONTRACTOR shall document the date the level of care assessment completed in the member’s file; any level of care assessments prompted by a request for a change in level of services shall be submitted to TENNCARE for determination.
 
  2.9.6.9.3.1.2   Facilitate access to physical and/or behavioral health services as needed, including transportation to services as specified in Section 2.6.1 and Attachment XI; except as provided in Sections 2.11.1.8 or 2.6.5, transportation for HCBS is not included;
 
  2.9.6.9.3.1.3   Monitor and ensure the provision of covered physical health, behavioral health, and/or long-term care services as well as services provided as a cost-effective alternative to other covered services and ensure that services provided meet the member’s needs;
 
  2.9.6.9.3.1.4   Provide assistance in resolving concerns about service delivery or providers;
 
  2.9.6.9.3.1.5   Coordinate with a member’s PCP, specialists and other providers, such as the member’s mental health case manager, to facilitate a comprehensive, holistic, person-centered approach to care;
 
  2.9.6.9.3.1.6   Contact providers and workers on a periodic basis and coordinate with providers and workers to collaboratively address issues regarding member service delivery and to maximize community placement strategies;
 
  2.9.6.9.3.1.7   Share relevant information with and among providers and others when information is available and it is necessary to share for the well-being of the member;

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  2.9.6.9.3.1.8   Determine the appropriate course as specified herein upon (1) receipt of any contact made by or on behalf of a member, regardless of source, which asserts that the member’s needs are not met by currently authorized services; (2) the member’s hospitalization; or (3) other circumstances which warrant review and potential modification of services authorized for the member;
 
  2.9.6.9.3.1.9   Ensure that all PASRR requirements are met prior to the member’s admission to a nursing facility;
 
  2.9.6.9.3.1.10   Update consent forms as necessary; and
 
  2.9.6.9.3.1.11   Assure that the organization of and documentation included in the member’s file meets all applicable CONTRACTOR standards.
 
  2.9.6.9.3.2   The CONTRACTOR shall provide to contract providers, including but not limited to hospitals, nursing facilities, physicians, and behavioral health providers, and caregivers information regarding the role of the care coordinator and shall request providers and caregivers to notify a member’s care coordinator, as expeditiously as warranted by the member’s circumstances, of any significant changes in the member’s condition or care, hospitalizations, or recommendations for additional services. The CONTRACTOR shall provide training to key providers and caregivers regarding the value of this communication and remind them that the member identification card indicates if a member is enrolled in CHOICES.
 
  2.9.6.9.3.3   The CONTRACTOR shall have systems in place to facilitate timely communication between internal departments and the care coordinator to ensure that each care coordinator receives all relevant information regarding his/her members, e.g., member services, disease management, utilization management, and claims processing. The care coordinator shall follow-up on this information as appropriate, e.g., documentation in the member’s plan of care, monitoring of outcomes, and, as appropriate, needs reassessment and updating the plan of care.
 
  2.9.6.9.3.4   The CONTRACTOR shall monitor and evaluate a member’s emergency department and behavioral health crisis service utilization to determine the reason for these visits. The care coordinator shall take appropriate action to facilitate appropriate utilization of these services, e.g., communicating with the member’s providers, educating the member, conducting a needs reassessment, and/or updating the member’s plan of care and to better manage the member’s physical health or behavioral health condition(s).
  2.9.6.9.3.5   The CONTRACTOR shall develop policies and procedures to ensure that care coordinators are actively involved in discharge planning when a CHOICES member is hospitalized. The CONTRACTOR shall define circumstances that require that hospitalized CHOICES members receive a face-to-face visit to complete a needs reassessment and an update to the member’s plan of care as needed.

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  2.9.6.9.3.6   The CONTRACTOR shall ensure that at each face-to-face visit the care coordinator makes the following observations and documents the observations in the member’s file:
  2.9.6.9.3.6.1   Member’s physical condition including observations of the member’s skin, weight changes and any visible injuries;
 
  2.9.6.9.3.6.2   Member’s physical environment;
 
  2.9.6.9.3.6.3   Member’s satisfaction with services and care;
 
  2.9.6.9.3.6.4   Member’s upcoming appointments;
 
  2.9.6.9.3.6.5   Member’s mood and emotional well-being;
 
  2.9.6.9.3.6.6   Member’s falls and any resulting injuries;
 
  2.9.6.9.3.6.7   A statement by the member regarding any concerns or questions; and
 
  2.9.6.9.3.6.8   A statement from the member’s representative or caregiver regarding any concerns or questions (when the representative/caregiver is available).
 
  2.9.6.9.3.7   The CONTRACTOR shall identify and immediately respond to problems and issues including but not limited to:
 
  2.9.6.9.3.7.1   Service gaps; and
 
  2.9.6.9.3.7.2   Complaints or concerns regarding the quality of care rendered by providers, workers, or care coordination staff.
  2.9.6.9.4   Minimum Care Coordinator Contacts
  2.9.6.9.4.1   The care coordinator shall conduct all needs assessment and care planning activities, and shall make all minimum care coordinator contacts as specified below in the member’s place of residence, except under extenuating circumstances (such as assessment and care planning conducted during the member’s hospitalization, or upon the member’s request), which shall be documented in writing.
 
  2.9.6.9.4.1.1   While the CONTRACTOR may grant a member’s request to conduct certain care coordination activities outside his or her place of residence, the CONTRACTOR is responsible for assessing the member’s living environment in order to identify any modifications that may be needed and to identify and address, on an ongoing basis, any issues which may affect the member’s health, safety and welfare. Repeated refusal by the member to allow the care coordinator to conduct visits in his or her home may, subject to review and approval by TENNCARE, constitute grounds for disenrollment from CHOICES Groups 2 or 3, if the CONTRACTOR is unable to properly perform monitoring and other contracted functions and to confirm that the member’s needs can be safely and effectively met in the home setting.

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  2.9.6.9.4.2   A member may initiate a request to opt out of some of the minimum face-to-face contacts, but only with TENNCARE review of circumstances and approval. The CONTRACTOR shall not encourage a member to request a reduction in face-to- face visits by the care coordinator.
 
  2.9.6.9.4.3   The CONTRACTOR shall ensure that care coordinators assess each member’s need for contact with the care coordinator, to meet the member’s individual need and ensure the member’s health and welfare. At a minimum, CHOICES members shall be contacted by their care coordinator according to the following timeframes:
 
  2.9.6.9.4.3.1   Members shall receive a face-to-face visit from their care coordinator in their residence within the timeframes specified in Sections 2.9.6.2.4, 2.9.6.2.5 and 2.9.6.3.
 
  2.9.6.9.4.3.2   Members who are newly admitted to a nursing facility when the admission has not been authorized by the CONTRACTOR, shall receive a face-to-face visit from their care coordinator within ten (10) days of notification of admission.
 
  2.9.6.9.4.3.3   Members in CHOICES Group 2 who have transitioned from a nursing facility to the community shall be contacted per the applicable timeframe specified in Section 2.9.6.8.
 
  2.9.6.9.4.3.4   Within five (5) business days of scheduled initiation of services, the member’s care coordinator/care coordination team shall contact members in CHOICES Groups 2 and 3 who begin receiving HCBS after the date of enrollment in CHOICES to confirm that services are being provided and that the member’s needs are being met (such initial contact may be conducted by phone).
 
  2.9.6.9.4.3.5   Within five (5) business days of scheduled initiation of HCBS in the updated plan of care, the member’s care coordinator/care coordination team shall contact members in CHOICES Groups 2 and 3 to confirm that services are being provided and that the member’s needs are being met (such initial contact may be conducted by phone).
 
  2.9.6.9.4.3.6   Members in CHOICES Group 1 (who are residents of a nursing facility) shall receive a face-to-face visit from their care coordinator at least twice a year at a reasonable interval.
 
  2.9.6.9.4.3.7   Members in CHOICES Group 2 shall be contacted by their care coordinator at least monthly either in person or by telephone. These members shall be visited in their residence face-to-face by their care coordinator at least quarterly.
 
  2.9.6.9.4.3.8   Members in CHOICES Group 3 shall be contacted by their care coordinator at least quarterly either in person or by telephone. These members shall be visited in their residence face-to-face by their care coordinator a minimum of semiannually.
 
  2.9.6.9.5   The CONTRACTOR shall ensure a member’s care coordinator/care coordination team coordinates with Medicare payers, Medicare Advantage plans, and Medicare

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      providers as appropriate to coordinate the care and benefits of members who are also eligible for Medicare (see Section 2.9.12).
  2.9.6.9.6   Member Case Files
  2.9.6.9.6.1   The care coordinator/care coordination team shall maintain individual files for each assigned CHOICES member.
 
  2.9.6.9.6.2   For members in CHOICES Group 1, the files shall contain at a minimum:
 
  2.9.6.9.6.2.1   Pertinent demographic information regarding the member including the name and contact information of any representative and a list of other persons authorized by the member to have access to health care (including long-term care) related information;
 
  2.9.6.9.6.2.2   Any supplements to the nursing facility plan of care, as applicable;
 
  2.9.6.9.6.2.3   A signed acknowledgement of the member’s patient liability amount and the member’s understanding regarding his/her responsibility with respect to payment of patient liability, including the potential consequences for non-payment; and
 
  2.9.6.9.6.2.4   Transition assessment and transition plan, if applicable.
 
  2.9.6.9.6.3   For members in CHOICES Groups 2 or 3, the files shall contain at a minimum:
 
  2.9.6.9.6.3.1   The most current plan of care, including the detailed plan for back-up providers in situations when regularly scheduled providers are unavailable or do not arrive as scheduled;
 
  2.9.6.9.6.3.2   List of providers who will be providing home health, private duty nursing and HCBS paid for by other payors;
 
  2.9.6.9.6.3.3   Written confirmation of the member’s decision regarding participation in consumer direction of HCBS;
 
  2.9.6.9.6.3.4   For members who are self-directing any health care tasks, a copy of the physician’s order;
 
  2.9.6.9.6.3.5   For members in CHOICES Group 2, a completed risk assessment and a risk agreement signed by the member or his/her representative; and documentation that the person’s needs can be safely and effectively met in the community and at a cost that does not exceed nursing facility care, including signed acknowledgement of understanding by the member or his/her representative that a change in needs or circumstances that would result in the cost neutrality cap being exceeded or that would result in the CONTRACTOR’s inability to safely and effectively meet the member’s needs in the community and within the cost neutrality cap may result in the member’s disenrollment from CHOICES Group 2;
 
  2.9.6.9.6.3.6   For members in CHOICES Group 2, the cost neutrality cap provided by TENNCARE, a determination by the CONTRACTOR that the projected cost of

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      HCBS, home health, and private duty nursing services will not exceed the member’s cost neutrality cap, and signed acknowledgement of understanding by the member or his/her representative that a change in his/her needs or circumstances that would result in the cost neutrality cap being exceeded or that would result in the MCO’s inability to safely and effectively meet a member’s needs in the community and within the cost neutrality cap may result in the member’s disenrollment from CHOICES Group 2 ; and
 
  2.9.6.9.6.3.7   For members in CHOICES Group 3, signed acknowledgement regarding the expenditure cap.
 
  2.9.6.9.6.4   For all CHOICES members, files shall contain at a minimum:
 
  2.9.6.9.6.4.1   For CHOICES members in Groups 1 and 2, Freedom of Choice form signed by the member or his/her representative;
 
  2.9.6.9.6.4.2   Evidence that a care coordinator/the care coordination team provided the member with CHOICES member education materials (see Section 2.17.7 of this Agreement), reviewed the materials, and provided assistance with any questions;
 
  2.9.6.9.6.4.3   Evidence that a care coordinator/the care coordination team provided the member with education about the member’s ability to use an advance directive and documentation of the member’s decision;
 
  2.9.6.9.6.4.4   The most recent level of care assessment and needs assessment (if applicable);
 
  2.9.6.9.6.4.5   Documentation of the member’s choice of contract providers for long-term care services;
 
  2.9.6.9.6.4.6   Signed consent forms as necessary in order to share confidential information with and among providers consistent with all applicable state and federal laws and regulations;
 
  2.9.6.9.6.4.7   A list of emergency contacts approved by the member;
 
  2.9.6.9.6.4.8   Documentation of observations completed during face-to-face contact by the care coordinator; and
 
  2.9.6.9.6.4.9   The member’s TennCare eligibility end date.
  2.9.6.10   Additional Requirements for Care Coordination Regarding Consumer Direction of HCBS
  2.9.6.10.1   In addition to the roles and responsibilities otherwise specified in this Section 2.9.6, the CONTRACTOR shall ensure that the following additional care coordination functions related to consumer direction of HCBS are fulfilled.
 
  2.9.6.10.2   The CONTRACTOR shall be responsible for providing all needed eligible HCBS using contract providers until all necessary requirements have been fulfilled in order to implement consumer direction of HCBS, including but not limited to: the FEA verifies that workers for these services meet all necessary requirements (see Section

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  2.9.7.6.1   of this Agreement); service agreements are completed and signed; and authorizations for consumer directed services are in place. The CONTRACTOR, in conjunction with the FEA, shall facilitate a seamless transition between contract providers and workers and ensure that there are no interruptions or gaps in services.
  2.9.6.10.3   If a member is interested in participating in consumer direction of HCBS and the member does not intend to appoint a representative, the care coordinator shall determine the extent to which the member may require assistance to direct his/her services (see Section 2.9.7.4.5). If the care coordinator determines that the member requires assistance to direct his/her services, based upon the results of a completed self-assessment instrument developed by TENNCARE, the care coordinator shall inform the member that he/she will need to designate a representative to assume the consumer direction functions on his/her behalf (see Section 2.9.7.4.5.1).
 
  2.9.6.10.4   The member’s care coordinator/care coordination team shall ensure that the person identified to serve as the representative meets all qualifications (see Section 2.9.7.2.1) and that a representative agreement is completed and signed by the member prior to forwarding a referral to the FEA (see Section 2.9.7.4.7).
 
  2.9.6.10.5   Within two (2) business days of signing the representative agreement or completion of the self-assessment instrument if the member does not use a representative, the CONTRACTOR shall forward to the FEA a referral initiating the member’s participation in consumer direction of HCBS.
 
  2.9.6.10.6   The care coordinator, in conjunction with the FEA, shall assist the member and/or the representative as needed in developing a back-up plan for consumer direction that adequately identifies how the member will address situations when a scheduled worker fails to show up. The member and his/her representative (as applicable) shall have primary responsibility for the development of the back-up plan for consumer directed services. The back-up plan shall include the names and telephone number of contacts for alternate care, the order in which contact shall be made and the services to be provided by contacts. Back-up workers may include paid and non-paid supports; however, it is the responsibility of the member electing consumer direction and/or his/her representative to secure paid (as well as unpaid) back-up staff who are willing and available to serve in this capacity. The CONTRACTOR shall not be expected or required to maintain contract providers “on standby” to serve in a backup capacity for services a member has elected to receive through consumer direction. All persons and/or organizations noted in back-up plan for consumer directed services shall first be contacted by the member and/or representative to determine their willingness and availability to serve as back-up workers. The care coordinator shall follow-up with these persons and/or organizations to confirm their willingness and availability to provide care when needed.
 
  2.9.6.10.7   On an ongoing basis, the CONTRACTOR shall ensure that needs reassessments and updates to the plan of care occur per requirements specified in Sections 2.9.6.9 of this Agreement. The care coordinator shall ensure that the member’s supports broker is invited to participate in these meetings.
 
  2.9.6.10.8   Within two (2) business days of receipt of the notification from the FEA indicating that all requirements have been fulfilled and the date that the consumer direction can begin for a member, the CONTRACTOR shall forward to the FEA an authorization

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      for consumer directed services for that member. Each authorization for consumer directed services shall include the required elements for a referral (see Section 2.9.7.4.7) including: authorized service, authorized units of service, including amount, frequency and duration, start and end dates, and service code.
 
  2.9.6.10.9   The member’s care coordinator/care coordination team shall work with and coordinate with a member’s supports broker in implementing and monitoring consumer direction of HCBS (see Section 2.9.7.3.4).
 
  2.9.6.10.10   The CONTRACTOR shall establish a process that allows for the efficient exchange of all relevant member information between the CONTRACTOR and the FEA.
 
  2.9.6.10.11   The care coordinator shall determine a member’s interest in enrolling in or continuing to participate in consumer direction annually and shall document the member’s decision in the member’s plan of care.
 
  2.9.6.10.12   If at any time the care coordinator or FEA suspects abuse or neglect on the part of the representative or worker, the care coordinator and/or FEA shall report the allegations to the CONTRACTOR. The CONTRACTOR shall report the representative and/or worker to APS. The representative and/or worker shall immediately be released from his/her duties until the APS investigation is complete. The care coordinator shall work with the member to find a new representative, and the FEA shall work with the member to find a suitable replacement worker. If the allegations are substantiated as a result of the APS investigation, the representative and/or worker shall no longer be allowed to participate in the CHOICES program in any capacity.
 
  2.9.6.10.13   In the event the CONTRACTOR believes that it cannot safely and effectively serve the member in the community, the care coordinator, with the assistance of and input from the FEA, shall review with the member the previously developed risk agreement and update it to ensure that any additional identified risks are incorporated and measures are identified to mitigate risks. The representative (if applicable) shall participate in the process. The updated risk assessment shall be signed by the member or representative and the care coordinator. A copy shall be given to the member or representative. The care coordinator and the FEA shall file a copy in the member’s files. If the CONTRACTOR does not believe the member can be safely and effectively served in the community, the CONTRACTOR may request to involuntarily withdraw the member from consumer direction of HCBS (see Section 2.9.7.9).
  2.9.6.11   Care Coordination Staff
  2.9.6.11.1   The CONTRACTOR shall establish qualifications for care coordinators. At a minimum, care coordinators shall be an RN or LPN or have a bachelor’s degree in social work, nursing or other health care profession. A care coordinator’s direct supervisor shall be a licensed social worker or registered nurse with a minimum of two (2) years of relevant health care (preferably long-term care) experience.
 
  2.9.6.11.2   If the CONTRACTOR elects to use a care coordination team, the CONTRACTOR’s policies and procedures shall specify the qualifications, experience and training of each member of the team and ensure that functions specific to the assigned care coordinator are performed by a qualified care coordinator (see Section 2.9.6.4.4).

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  2.9.6.11.3   The CONTRACTOR shall ensure an adequate number of care coordinators are available and that sufficient staffing ratios are maintained to address the needs of CHOICES members and meet all the requirements described in this Agreement.
 
  2.9.6.11.4   The CONTRACTOR shall monitor staffing ratios and adjust ratios as necessary to ensure that care coordinators are able to meet the requirements of this Agreement and address members’ needs.
 
  2.9.6.11.5   While care coordination staffing ratios are not specified, the CONTRACTOR shall submit to TennCare for review and approval at least 120 days in advance of CHOICES implementation in the Grand Region covered by this Agreement a Care Coordination Staffing Plan, which shall specify the number of care coordinators, care coordination supervisors, other care coordination team members the CONTRACTOR plans to initially employ, the ratio of care coordinators to members the CONTRACTOR plans to maintain, an explanation of the methodology for determining such ratio, and how the CONTRACTOR will ensure that such ratios are sufficient to fulfill the requirements specified in this Agreement and roles and responsibilities for each member of the care coordination team. TENNCARE shall notify the CONTRACTOR in writing if the Care Coordination Staffing Plan is insufficient and may require modifications to ensure, prior to implementation of CHOICES, that the CONTRACTOR has sufficient care coordination staff. After CHOICES has been implemented, the CONTRACTOR shall notify TENNCARE in writing of substantive changes to its Care Coordination Staffing Plan, including a variance of twenty (20) percent or more from the planned staffing ratio. TENNCARE may request changes in the CONTRACTOR’s Care Coordination Staffing Plan at any time it determines that the CONTRACTOR does not have sufficient care coordination staff to properly and timely perform its obligations under this Agreement.
 
  2.9.6.11.6   The CONTRACTOR shall establish a system to assign care coordinators and to notify the member of his/her assigned care coordinator’s name and contact information in accordance with Section 2.9.6.4.3.
 
  2.9.6.11.7   The CONTRACTOR shall ensure that members have a telephone number to call to directly contact (without having to disconnect or place a second call) their care coordinator or a member of their care coordination team (if applicable) during normal business hours. If the member’s care coordinator or a member of the member’s care coordination team is not available, the call shall be answered by another qualified staff person in the care coordination unit. If the call requires immediate attention from a care coordinator, the staff member answering the call shall immediately transfer the call to the member’s care coordinator (or another care coordinator if the member’s care coordinator is not available) as a “warm transfer” (see definition in Section 1). After normal business hours, calls that require immediate attention by a care coordinator shall be transferred to a care coordinator as specified in Section 2. 18.1.6.
 
  2.9.6.11.8   The CONTRACTOR shall permit members to change to a different care coordinator if the member desires and there is an alternative care coordinator available. Such availability may take into consideration the CONTRACTOR’s need to efficiently deliver care coordination in accordance with requirements specified herein, including

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      for example, the assignment of a single care coordinator to all CHOICES members receiving nursing facility or community-based residential alternative services from a particular provider. Subject to the availability of an alternative care coordinator, the CONTRACTOR may impose a six (6) month lock-in period with an exception for cause after a member has been granted one (1) change in care coordinators.
 
  2.9.6.11.9   In order to ensure quality and continuity of care, the CONTRACTOR shall make efforts to minimize the number of changes in care coordinator assigned to a member. A CONTRACTOR initiated change in care coordinators may be appropriate in the following circumstances:
 
  2.9.6.11.9.1   Care coordinator is no longer employed by the CONTRACTOR;
 
  2.9.6.11.9.2   Care coordinator has a conflict of interest and cannot serve the member;
 
  2.9.6.11.9.3   Care coordinator is on temporary leave from employment; and
 
  2.9.6.11.9.4   Care coordinator caseloads must be adjusted due to the size or intensity of an individual care coordinator’s caseload.
 
  2.9.6.11.10   The CONTRACTOR shall develop policies and procedures regarding notice to members of care coordinator changes initiated by either the CONTRACTOR or the member, including advance notice of planned care coordinator changes initiated by the CONTRACTOR.
 
  2.9.6.11.11   The CONTRACTOR shall ensure continuity of care when care coordinator changes are made whether initiated by the member or by the CONTRACTOR. The CONTRACTOR shall demonstrate use of best practices by encouraging newly assigned care coordinators to attend a face-to-face transition visit with the member and the out-going care coordinator when possible.
 
  2.9.6.11.12   The CONTRACTOR shall provide initial training to newly hired care coordinators and ongoing training at least annually to care coordinators. Initial training topics shall include at a minimum:
 
  2.9.6.11.12.1   The CHOICES program including a description of the CHOICES groups; eligibility for CHOICES enrollment; enrollment in CHOICES; enrollment targets for Groups 2 and 3, including reserve capacity and administration of waiting lists; and CHOICES benefits, including benefit limits, the individual cost neutrality cap for Group 2, the expenditure cap for Group 3, and the limited benefit package for members enrolled on the basis of Immediate Eligibility;
 
  2.9.6.11.12.2   Facilitating CHOICES enrollment for current members;
 
  2.9.6.11.12.3   Level of care and needs assessment and reassessment, development of a plan of care, and updating the plan of care including training on the tools and protocols;
 
  2.9.6.11.12.4   Development and implementation of back-up plans;
 
  2.9.6.11.12.5   Consumer direction of HCBS;

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  2.9.6.11.12.6   Self-direction of health care tasks;
 
  2.9.6.11.12.7   Coordination of care for duals;
 
  2.9.6.11.12.8   Electronic visit verification;
 
  2.9.6.11.12.9   Conducting a home visit and use of the monitoring checklist;
 
  2.9.6.11.12.10   How to immediately identify and address service gaps;
 
  2.9.6.11.12.11   Management of critical transitions (including hospital discharge planning);
 
  2.9.6.11.12.12   Nursing facility diversion;
 
  2.9.6.11.12.13   Nursing facility to community transitions, including training on tools and protocols;
 
  2.9.6.11.12.14   For members in CHOICES Group 1, members’ responsibility regarding patient liability, including the consequences of not paying patient liability;
 
  2.9.6.11.12.15   Alzheimer’s, dementia and cognitive impairments;
 
  2.9.6.11.12.16   Traumatic brain injury;
 
  2.9.6.11.12.17   Physical disabilities;
 
  2.9.6.11.12.18   Disease management;
 
  2.9.6.11.12.19   Behavioral health;
 
  2.9.6.11.12.20   Evaluation and management of risk;
 
  2.9.6.11.12.21   Identifying and reporting abuse/neglect (see Section 2.24.4);
 
  2.9.6.11.12.22   Fraud and abuse, including reporting fraud and abuse;
 
  2.9.6.11.12.23   Advance directives and end of life care;
 
  2.9.6.11.12.24   HIPAA;
 
  2.9.6.11.12.25   Cultural competency;
 
  2.9.6.11.12.26   Disaster planning; and
 
  2.9.6.11.12.27   Available community resources for non-covered services.
 
  2.9.6.11.13   The CONTRACTOR shall establish roles and job responsibilities for care coordinators. The job responsibilities shall include a description of activities and required timeframes for completion. These activities shall include the requirements specified in this Section 2.9.6.

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  2.9.6.12   Care Coordination Monitoring
  2.9.6.12.1   The CONTRACTOR shall develop a comprehensive program for monitoring, on an ongoing basis, the effectiveness of its care coordination processes. The CONTRACTOR shall immediately remediate all individual findings identified through its monitoring process, and shall also track and trend such findings and remediations to identify systemic issues of poor performance and/or non-compliance, implement strategies to improve care coordination processes and resolve areas of non-compliance, and shall measure the success of such strategies in addressing identified issues. At a minimum, the CONTRACTOR shall ensure that:
 
  2.9.6.12.1.1   Care coordination tools and protocols are consistently and objectively applied and outcomes are continuously measured to determine effectiveness and appropriateness of processes;
 
  2.9.6.12.1.2   Level of care assessments and reassessments occur on schedule and are submitted to TENNCARE in accordance with requirements in Section 2.9.6.9.3.1.1;
 
  2.9.6.12.1.3   Needs assessments and reassessment, as applicable, occur on schedule and in compliance with this Agreement;
 
  2.9.6.12.1.4   Plans of care for CHOICES Groups 2 and 3 are developed and updated on schedule and in compliance with this Agreement;
 
  2.9.6.12.1.5   Plans of care for CHOICES Groups 2 and 3 reflect needs identified in the needs assessment and reassessment process;
 
  2.9.6.12.1.6   Plans of care for CHOICES Groups 2 and 3 are appropriate and adequate to address member needs;
 
  2.9.6.12.1.7   Services are delivered as described in the plan of care and authorized by the CONTRACTOR;
 
  2.9.6.12.1.8   Services are appropriate to address the member’s needs;
 
  2.9.6.12.1.9   Services are delivered in a timely manner;
 
  2.9.6.12.1.10   Service utilization is appropriate;
 
  2.9.6.12.1.11   Service gaps are identified and addressed in a timely manner;
 
  2.9.6.12.1.12   Minimum care coordinator contacts are conducted;
 
  2.9.6.12.1.13   Care coordinator-to-member ratios are appropriate;
 
  2.9.6.12.1.14   The cost neutrality cap for members in CHOICES Group 2 and the expenditure cap for members in CHOICES Group 3 are monitored and appropriate action is taken if a member is nearing or exceeds his/her cost neutrality or expenditure cap; and

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  2.9.6.12.1.15   That benefit limits are monitored and that appropriate action is taken if a member is nearing or exceeds a benefit limit.
 
  2.9.6.12.2   The CONTRACTOR shall provide to TENNCARE the reports required by Section 2.30.
 
  2.9.6.12.3   The CONTRACTOR shall purchase and implement an electronic visit verification system to monitor member receipt and utilization of HCBS including at a minimum, personal care, attendant care, homemaker services and home-delivered meals. The CONTRACTOR shall select its own electronic visit verification vendor and shall ensure, in the development of such system, the following minimal functionality:
 
  2.9.6.12.3.1   The ability to log the arrival and departure of individual provider staff person or consumer direction worker;
 
  2.9.6.12.3.2   The ability to verify in accordance with business rules that services are being delivered in the correct location (e.g., the member’s home);
 
  2.9.6.12.3.3   The ability to verify the identity of the individual provider staff person or worker providing the service to the member;
 
  2.9.6.12.3.4   The ability to match services provided to a member with services authorized in the plan of care;
 
  2.9.6.12.3.5   The ability to ensure that the provider/worker delivering the service is authorized to deliver such services;
 
  2.9.6.12.3.6   The ability to establish a schedule of services for each member which identifies the time at which each service is needed, and the amount, frequency, duration and scope of each service, and to ensure adherence to the established schedule;
 
  2.9.6.12.3.7   The ability to provide immediate (i.e., “real time”) notification to care coordinators if a provider or worker does not arrive as scheduled or otherwise deviates from the authorized schedule so that service gaps and the reason the service was not provided as scheduled, are immediately identified and addressed, including through the implementation of back-up plans, as appropriate;
 
  2.9.6.12.3.8   The ability for a provider of home-delivered meals to log in and enter the meals that have been delivered during the day, including the member’s name, time delivered and the reason a meal was not delivered (when applicable);
 
  2.9.6.12.3.9   The ability for a provider, e.g., adult day care provider, to log in and enter attendance for the day;
 
  2.9.6.12.3.10   The ability for the provider/worker to submit claims to the CONTRACTOR (claims from workers shall be submitted initially to the FEA, and the FEA shall provide claims information to the CONTRACTOR as specified in the subcontract with the FEA; see Section 2.26); and
 
  2.9.6.12.3.11   The ability to reconcile paid claims with service authorizations.

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  2.9.6.12.4   The CONTRACTOR shall not require that provider staff delivering home-delivered meals log in at arrival and departure. Instead, the provider may opt to log in on a daily basis after meals have been delivered and enter information on all the meals that were delivered that day (see Section 2.9.6.12.3.8 above).
 
  2.9.6.12.5   The CONTRACTOR shall monitor and use information from the electronic visit verification system to verify that services are provided as specified in the plan of care, and in accordance with the established schedule, including the amount, frequency, duration, and scope of each service, and that services are provided by the authorized provider/worker; and to identify and immediately address service gaps, including late and missed visits. The CONTRACTOR shall monitor services anytime a member is receiving services, including after the CONTRACTOR’s regular business hours.
 
  2.9.6.12.6   The CONTRACTOR shall develop and maintain an electronic case management system that includes the functionality to ensure compliance with all requirements specified in the Section 1115 TennCare Demonstration Waiver, federal and state laws and regulations, this Agreement, and TennCare policies and protocols, including but not limited to the following:
 
  2.9.6.12.6.1   The ability to capture and track key dates and timeframes specified in this Agreement, e.g., as applicable, date of referral for potential CHOICES enrollment, date the level of care assessment and plan of care were submitted to TENNCARE, date of CHOICES enrollment, date of development of the plan of care, date of authorization of the plan of care, date of initial service delivery for each service in the plan of care, date of each level of care and needs reassessment, date of each update to the plan of care, and dates regarding transition from a nursing facility to the community;
 
  2.9.6.12.6.2   The ability to capture and track compliance with minimum care coordination contacts as specified in Section 2.9.6.9.4 of this Agreement;
 
  2.9.6.12.6.3   The ability to notify the care coordinator about key dates, e.g., TennCare eligibility end date, date for annual level of care reassessment, date of needs reassessment, and date for update to the plan of care;
 
  2.9.6.12.6.4   The ability to capture and track eligibility/enrollment information, level of care assessments and reassessments, and needs assessments and reassessments;
 
  2.9.6.12.6.5   The ability to capture and monitor the plan of care;
 
  2.9.6.12.6.6   The ability to track requested and approved service authorizations, including covered long-term care services and any services provided as a cost-effective alternative to other covered services;
 
  2.9.6.12.6.7   The ability to document all referrals received by the care coordinator on behalf of the member for covered long-term care services; home health and private duty nursing services; other physical or behavioral health services needed to help the member maintain or improve his or her physical or behavioral health status or functional abilities and maximize independence; and other social support services and assistance needed in order to ensure the member’s health, safety and welfare,

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      and as applicable, to delay or prevent the need for more expensive institutional placement, including notes regarding how such referral was handled by the care coordinator;
 
  2.9.6.12.6.8   The ability to establish a schedule of services for each member which identifies the time at which each service is needed and the amount, frequency, duration and scope of each service;
 
  2.9.6.12.6.9   The ability to provide, via electronic interface with the electronic visit verification system, service authorizations on behalf of a CHOICES member, including the schedule at which each service is needed;
 
  2.9.6.12.6.10   The ability to provide, via electronic interface with the FEA, referrals and service authorizations;
 
  2.9.6.12.6.11   The ability to track service delivery against authorized services and providers;
 
  2.9.6.12.6.12   The ability to track actions taken by the care coordinator to immediately address service gaps; and
 
  2.9.6.12.6.13   The ability to document case notes relevant to the provision of care coordination.
2.9.7 Consumer Direction of HCBS
  2.9.7.1   General
  2.9.7.1.1   The CONTRACTOR shall offer consumer direction of HCBS to all CHOICES Group 2 and 3 members who are determined by a care coordinator, through the needs assessment/reassessment process, to need attendant care, personal care, homemaker, in-home respite, companion care services and/or any other service specified in TennCare rules and regulations as available for consumer direction. (Companion care is only available for persons electing consumer direction of HCBS.) A service that is not specified in TennCare rules and regulations as available for consumer direction shall not be consumer directed. Consumer direction in CHOICES affords members the opportunity to have choice and control over how eligible HCBS are provided, who provides the services and how much workers are paid for providing care, up to a specified maximum amount established by TENNCARE (see Section 2.9.7.6.11). Member participation in consumer direction of HCBS is voluntary. Members may elect to participate in or withdraw from consumer direction of HCBS at any time, service by service, without affecting their enrollment in CHOICES. To the extent possible, the member shall provide his/her care coordinator ten (10) days advance notice regarding his/her intent to no longer direct one or more eligible HCBS or to withdraw from participation in consumer direction of HCBS entirely. The CONTRACTOR shall respond to the member’s request in keeping with the timeframes and processes set forth in this Section, in order to facilitate a seamless transition to appropriate service delivery. TENNCARE shall establish reasonable limitations on the frequency with which members may opt into and out of consumer direction of HCBS.

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  2.9.7.1.2   Consumer direction is a process by which eligible HCBS are delivered; it is not a service. If a member chooses not to direct his/her care, he/she shall receive authorized HCBS through contract providers. While the denial of a member’s request to participate in consumer direction or the termination of a member’s participation in consumer direction gives rise to due process including the right to fair hearing, such appeals shall be processed by the TennCare Division of Long Term Care rather than the TennCare Solutions Units, which manages medical appeals pertaining to TennCare benefits (i.e., services).
 
  2.9.7.1.3   Members who participate in consumer direction of HCBS choose either to serve as the employer of record of their workers or to designate a representative (see definition below in Section 2.9.7.2.1) to serve as the employer of record on his/her behalf. As the employer of record the member or his/her representative is responsible for the following:
 
  2.9.7.1.3.1   Hiring/Firing workers;
 
  2.9.7.1.3.2   Determining workers’ duties and developing job descriptions;
 
  2.9.7.1.3.3   Scheduling workers;
 
  2.9.7.1.3.4   Supervising workers;
 
  2.9.7.1.3.5   Evaluating worker performance and addressing any identified deficiencies or concerns;
 
  2.9.7.1.3.6   Setting wages up to a specified maximum amount established by TENNCARE;
 
  2.9.7.1.3.7   Training workers to provide personalized care based on the member’s needs and preferences;
 
  2.9.7.1.3.8   Reviewing and approving timesheets;
 
  2.9.7.1.3.9   Reviewing and ensuring proper documentation for services provided; and
 
  2.9.7.1.3.10   Developing and activating as needed a back-up plan to address instances when a scheduled worker does not show up.
 
  2.9.7.1.3.10.1   The back-up plan developed by the member may include both paid and unpaid supports; however, it is the responsibility of the member electing consumer direction and/or his/her representative to secure paid (as well as unpaid) back-up staff who are willing and available to serve in this capacity for consumer directed services. The CONTRACTOR shall not be expected or required to maintain contract providers “on standby” to serve in a back-up capacity for services a member has elected to receive through consumer direction. The member must make arrangements for the provision of needed medical care and does not have the option of going without needed services.
 
  2.9.7.1.3.10.2   In some respects, the back-up plan for consumer direction is similar to the backup plan that contract providers are obligated to maintain (i.e., to address instances where an agency staff person does not show up). As the employer of record, the

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      member and/or representative have willingly taken on the responsibilities that would otherwise be performed by the contract provider agency. However, the back-up plan for consumer directed workers is more comprehensive in that it is intended to facilitate the provision of needed care even when another paid worker is not available and is thus comparable to and shall be integrated with the backup plan which is part of the member’s plan of care and which also addresses (as applicable) instances in which a contract provider is authorized to provide care and the contract provider’s back-up plan fails. The CONTRACTOR shall assess the adequacy of the back-up plan.
 
  2.9.7.2   Representative
 
  2.9.7.2.1   A member may designate, or have appointed by a guardian, a representative to assume the consumer direction responsibilities on his/her behalf. A representative shall meet, at minimum the following requirements: be at least 18 years of age, have a personal relationship with the member and understand his/her support needs; know the member’s daily schedule and routine, medical and functional status, medication regimen, likes and dislikes, and strengths and weaknesses; and be physically present in the member’s residence on a regular basis or at least at a frequency necessary to supervise and evaluate workers.
 
  2.9.7.2.2   In order to participate in consumer direction of HCBS with the assistance of a representative, one of the following must apply: (1) the member must have the ability to designate a person to serve as his/her representative or (2) the member has a legally appointed representative who may serve as the member’s representative.
 
  2.9.7.2.3   The care coordinator shall determine if the member requires assistance in carrying out the responsibilities required for consumer direction and therefore requires a representative. The member’s care coordinator/care coordination team shall verify that a representative meets the qualifications as described in Section 2.9.7.2.1 above.
 
  2.9.7.2.4   A member’s representative shall not receive payment for serving in this capacity and shall not serve as the member’s worker for any consumer directed service. The CONTRACTOR shall use a representative agreement developed by TENNCARE to document a member’s choice of a representative for consumer direction of HCBS and the representative’s contact information, and to confirm the individual’s agreement to serve as the representative and to accept the responsibilities and perform the associated duties defined therein. Ongoing, the fiscal employer agent (FEA) shall notify the CONTRACTOR within one (1) business day when it becomes aware of any changes to a representative’s contact information. Conversely, the CONTRACTOR shall notify the FEA within one (1) business day when it becomes aware of any changes to a representative’s contact information.
 
  2.9.7.2.5   The representative agreement shall be signed by the member (or person authorized to sign on member’s behalf which shall not also be the representative for consumer direction) and the representative in the presence of the care coordinator. The care coordinator shall include the representative agreement in the member’s file and provide copies to the member and/or the member’s representative and the FEA (see Section 2.9.7.3 below).

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  2.9.7.2.6   A member may change his/her representative at any time. To the extent possible, the member shall notify his/her care coordinator ten (10) days in advance of initiating a change in representatives. The CONTRACTOR shall respond to the member’s request in keeping with the timeframes and processes set forth in this Section, in order to facilitate a seamless transition to a new representative. TENNCARE shall establish reasonable limitations on the frequency with which members may change representatives. In the event a member’s representative is unexpectedly no longer willing or able to fulfill the consumer direction functions on behalf of the member, the CONTRACTOR shall, as soon as possible, work with the member to find an alternate representative.
 
  2.9.7.2.7   The member’s care coordinator/care coordination team shall verify that the new representative meets the qualifications as described in Section 2.9.7.2.1 above. A new representative agreement shall be completed and signed, in the presence of a care coordinator, prior to the new representative assuming the respective responsibilities. The member’s care coordinator/care coordination team shall immediately notify the FEA when a member changes his/her representative and provide a copy of the representative agreement. The CONTRACTOR shall facilitate a seamless transition to the new representative, and ensure that there are no interruptions or gaps in services. As part of the needs assessment and plan of care process, the care coordinator shall educate the member about the importance of notifying the care coordinator prior to changing a representative.
 
  2.9.7.2.8   The FEA shall ensure that the new representative signs all service agreements (see Section 2.9.7.6.6).
 
  2.9.7.3   Fiscal Employer Agent (FEA)
 
  2.9.7.3.1   The CONTRACTOR shall enter into a subcontract with the FEA specified by TENNCARE to provide assistance to members choosing consumer direction.
 
  2.9.7.3.2   The FEA shall fulfill, at a minimum, the following financial administrative and supports broker functions for all CHOICES members electing consumer direction of HCBS:
 
  2.9.7.3.2.1   Assign a supports broker to each CHOICES member electing to participate in consumer direction of HCBS;
 
  2.9.7.3.2.2   Assist in identifying and addressing in the risk assessment and planning processes any additional risk associated with receiving consumer directed services;
 
  2.9.7.3.2.3   Provide initial and ongoing training to members and their representatives (as applicable) on consumer direction and other relevant issues (see Section 2.9.7.7 of this Agreement);
 
  2.9.7.3.2.4   Verify worker qualifications, including, as specified by TENNCARE, conduct background checks on workers, enroll workers into Medicaid, assign provider Medicaid ID numbers, and hold Medicaid provider agreements (see Section 2.9.7.6.1 of this Agreement);

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  2.9.7.3.2.5   Provide initial and ongoing training to workers on consumer direction and other relevant issues (see Section 2.9.7.7 of this Agreement);
  2.9.7.3.2.6   Assist the member and/or representative in developing and updating service agreements (see Section 2.9.7.6.6);
 
  2.9.7.3.2.7   Receive, review and process timesheets;
 
  2.9.7.3.2.8   Resolve timesheet discrepancies;
 
  2.9.7.3.2.9   Obtain documentation from the member and/or representative to ensure that services were provided prior to payment of timesheets;
  2.9.7.3.2.10   Withhold, file and pay applicable: federal, state and local income taxes; employment and unemployment taxes; and worker’s compensation;
  2.9.7.3.2.11   Pay workers for services rendered;
  2.9.7.3.2.12   Facilitate resolution of any disputes regarding payment to workers for services rendered;
  2.9.7.3.2.13   Monitor quality of services provided by workers; and
  2.9.7.3.2.14   Report to the CONTRACTOR on worker and/or staff identification of, response to, participation in and/or investigation of critical incidents (see Section 2.15.8).
  2.9.7.3.3   The FEA shall also fulfill, at a minimum, the following financial administrative and supports broker functions for CHOICES members electing consumer direction of HCBS on an as needed basis:
 
  2.9.7.3.3.1   Assist the member and/or representative in developing job descriptions;
 
  2.9.7.3.3.2   Assist the member and/or representative in locating and recruiting workers;
  2.9.7.3.3.3   Assist the member and/or representative in interviewing workers (developing questions, evaluating responses);
  2.9.7.3.3.4   Assist the member and/or representative in scheduling workers;
  2.9.7.3.3.5   Assist the member and/or representative in managing and monitoring payments to workers; and
 
  2.9.7.3.3.6   Assist the member and/or representative in monitoring and evaluating the performance of workers.
  2.9.7.3.4   The CONTRACTOR’s care coordination functions shall not duplicate the supports broker functions performed by the FEA or its subcontractor. A member’s care coordinator shall work with and coordinate with a member’s supports broker in implementing and monitoring consumer direction.

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  2.9.7.3.5   The CONTRACTOR’s subcontract with the FEA shall include the provisions specified by TENNCARE in the model FEA subcontract. The subcontract shall specify at a minimum the functions noted in Section 2.9.7.3.2 through 2.9.7.3.3. above (or a reference to the functions); the FEA’s responsibilities for communicating with the CONTRACTOR, members and workers; customer service requirements; processes and timeframes for authorizations of consumer directed services; processes and timeframes for service initiation; requirements and timeframes for processing employee payroll; process and requirements for billing; systems requirements and information exchange requirements; requirements for notifying MCO regarding readiness to initiate consumer direction of HCBS for a member; role and responsibility for training staff, contractors, members, representatives and workers regarding abuse and neglect plan protocols as described in Section 2.24.4.3 of this Agreement; and role and responsibility for critical incident reporting and management (see Section 2.15.8.4.6 of this Agreement).
  2.9.7.3.6   The CONTRACTOR in collaboration with the FEA shall establish a process that allows for the efficient exchange of all relevant member information between the CONTRACTOR and the FEA.
  2.9.7.3.7   The CONTRACTOR and FEA shall develop a protocol for interfaces and transfers of customer service inquiries per the requirements of Section 2.18 of this Agreement.
  2.9.7.3.8   The CONTRACTOR shall provide to the FEA copies of all relevant initial and updated member documents, including at a minimum, plans of care, representative agreements and risk agreements. The CONTRACTOR shall provide to the FEA all relevant documentation prior to service delivery.
  2.9.7.4   Needs Assessment/Plan of Care Process
  2.9.7.4.1   A CHOICES member may choose to direct needed eligible HCBS at anytime: during CHOICES intake, through the needs assessment/reassessment and plan of care and plan of care update processes; and outside of these processes. The care coordinator shall assess the member’s needs for eligible HCBS per requirements in Sections 2.9.6.2.4, 2.9.6.3 and 2.9.6.5, as applicable. The care coordinator shall use the plan of care process (including updates) to identify the eligible services that the member will direct and to facilitate the member’s enrollment in consumer direction of HCBS.
  2.9.7.4.2   The CONTRACTOR shall obtain written confirmation of the member’s decision to participate in consumer direction of HCBS.
  2.9.7.4.2.1   The care coordinator shall assist the member in identifying which of the needed eligible HCBS shall be consumer directed, provided by contract providers or a combination of both, in which case, there must be a set schedule which clearly defines when contract providers will be utilized. The CONTRACTOR shall not be expected or required to maintain contract providers “on standby” to serve in a back-up capacity for services a member has elected to receive through consumer direction.
  2.9.7.4.3   If the member intends to direct one or more needed eligible HCBS, throughout the period of time that consumer direction is being initiated, the CONTRACTOR shall arrange for the provision of needed HCBS through contract providers in accordance

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      with 2.9.6. The care coordinator shall obtain from the member his/her choice of contract providers who will provide HCBS until such time as workers are secured and ready to begin delivering care through consumer direction,.
  2.9.7.4.3.1   If a member has been assessed to need companion care services, the CONTRACTOR shall identify non-residential services that will offer interim support to address the member’s needs and assist the member in obtaining contract providers for these services.
  2.9.7.4.4   The CONTRACTOR shall be responsible for providing all needed eligible HCBS using contract providers until all necessary requirements have been fulfilled in order to implement consumer direction of HCBS, including but not limited to: the FEA verifies that workers for these services meet all necessary requirements (see Section 2.9.7.6.1 of this Agreement); service agreements are completed and signed; and authorizations for consumer directed services are in place. The CONTRACTOR, in conjunction with the FEA, shall facilitate a seamless transition between contract providers and workers and ensure that there are no interruptions or gaps in services.
  2.9.7.4.5   The care coordinator shall determine if the member will appoint a representative to assume the consumer direction functions on his/her behalf (see Section 2.9.7.6.1 of this Agreement). If the member does not intend to appoint a representative, the care coordinator shall determine the extent to which a member requires assistance to participate in consumer direction of HCBS, based upon the results of the member’s responses to the self-assessment instrument developed by TENNCARE. The self- assessment instrument shall be completed by the member with assistance from the member’s care coordinator as appropriate. The care coordinator shall file the completed self-assessment in the member’s file.
  2.9.7.4.5.1   If, based on the results of the self-assessment, the care coordinator determines that a member requires assistance to direct his/her services, and the member has not already designated a representative to assume the consumer direction functions, the care coordinator shall inform the member that he/she will need to designate a representative to assume the consumer direction functions on his/her behalf.
  2.9.7.4.5.2   The CONTRACTOR shall forward to TENNCARE for disposition, pursuant to TennCare policy, any cases in which the CONTRACTOR plans to deny participation in consumer direction because a care coordinator has determined that the health, safety and welfare of the member would be in jeopardy if the member participates in consumer direction without a representative but the member does not want to appoint a representative to assist in directing his/her services. The CONTRACTOR shall abide by TENNCARE’s decision.
  2.9.7.4.6   The member’s care coordinator/care coordination team shall ensure that the person identified to serve as the representative meets all qualifications (see Section 2.9.7.2.1 of this Agreement) and that a representative agreement is completed and signed by the member and the person prior to forwarding a referral to the FEA (see Section 2.9.7.4.7 below).
  2.9.7.4.7   Within two (2) business days of signing the representative agreement, the CONTRACTOR shall forward to the FEA a referral initiating the member’s

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      participation in consumer direction of HCBS. The referral shall include at a minimum: the date of the referral; the member’s name, address, telephone number, social security number; the name of the representative and telephone number, if applicable, (if known at the time) and social security number; member TennCare ID number; member’s CHOICES enrollment date; eligible selected HCBS, including amount, frequency and duration of each; and care coordinator name and contact information. The CONTRACTOR shall also forward to the FEA a copy of the written confirmation of the member’s decision to participate in consumer direction of HCBS.
  2.9.7.4.8   Within two (2) business days of receipt of the referral, the FEA shall assign a supports broker to the member and shall notify the care coordinator of the assignment.
  2.9.7.4.9   Within five (5) days of receipt of the referral, the FEA shall contact the member to inform the member of his/her assigned supports broker, provide contact information for the supports broker, and to begin the process of initiating consumer direction of HCBS.
  2.9.7.4.10   The care coordinator, in conjunction with the FEA, shall assist the member and/or the representative as needed in developing a back-up plan for consumer direction that adequately identifies how the member will address situations when a scheduled worker fails to show up. The member and his/her representative (as applicable) shall have primary responsibility for the development of the back-up plan for consumer directed services. The back-up plan shall include the names and telephone numbers of contacts for alternate care, the order in which contact shall be made and the services to be provided by contacts. Back-up workers may include paid and non-paid supports; however, it is the responsibility of the member electing consumer direction and/or his/her representative to secure paid (as well as unpaid) back-up staff who are willing and available to serve in this capacity. The CONTRACTOR shall not be expected or required to maintain contract providers “on standby” to serve in a backup capacity for services a member has elected to receive through consumer direction. All persons and/or organizations noted in back-up plan for consumer directed services shall first be contacted by the member and/or representative to determine their willingness and availability to serve as back-up workers. The care coordinator shall follow-up with these persons and/or organizations to confirm their willingness and availability to provide care when needed. The CONTRACTOR shall give a copy of the back-up plan, and any updates, to the FEA.
  2.9.7.4.11   The care coordinator, with assistance from the FEA, shall assist the member and/or the representative in reviewing and updating the risk agreement (as prescribed in Section 2.9.6.9.2.1.10 of this Agreement) in order to ensure that any additional risks associated with the member’s decision to direct his/her services are taken into consideration and that additional measures to mitigate these risks are identified. The representative (if applicable) shall participate in the process. The updated risk agreement shall be signed by the care coordinator and the member (or the member’s representative). A copy of the risk agreement shall be given to the member or the member’s representative and the FEA. The FEA and care coordinator shall file a copy of the updated risk assessment in the member’s files.

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  2.9.7.4.12   On an ongoing basis, the CONTRACTOR shall ensure that needs reassessments and updates to the plan of care occur per requirements specified in Sections 2.9.6.9 of this Agreement. The care coordinator shall ensure that the member’s supports broker is invited to participate in these meetings.
  2.9.7.5   Authorizations for Consumer Directed Services and Service Initiation
  2.9.7.5.1   Consumer direction of HCBS shall not be initiated until all requirements are fulfilled including but not limited to the following: (1) the FEA verifies that the member’s employer and related documentation is in order; (2) the FEA verifies that workers meet all qualifications, including participation in required training; (3) there is a signed service agreement specific to each individual worker (see Section 2.9.7.6.7 of this Agreement); and (4) the CONTRACTOR issues to the FEA an authorization for consumer directed services (see 2.9.7.5.6 below) for each service.
  2.9.7.5.2   The FEA shall work with the member to determine the appropriate level of assistance necessary to recruit, interview and hire workers and provide the assistance.
  2.9.7.5.3   Once potential workers are identified, the FEA shall verify that a potential worker meets all applicable qualifications (see Section 2.9.7.6.1 of this Agreement).
  2.9.7.5.4   The FEA shall ensure that a service agreement is signed between the member or member’s representative and his/her worker within five (5) business days following the FEA’s verification that a worker meets all qualifications.
  2.9.7.5.5   Within ten (10) days of receipt of the referral and every ten (10) days thereafter, the FEA shall update the care coordinator of the status of completing required functions necessary to initiate consumer direction, including obtaining workers for each identified consumer directed service and anticipated timeframes by which qualified workers shall be secured and consumer directed services may begin.
  2.9.7.5.6   The provision of consumer directed services shall begin as soon as possible but no longer than sixty (60) days from the date of the CONTRACTOR’s referral to the FEA. Prior to beginning the provision of consumer directed services, the FEA shall notify the CONTRACTOR that all requirements have been fulfilled, and the date that consumer directed services can begin. Within two (2) business days of receipt of the notification from the FEA, the CONTRACTOR shall forward to the FEA an authorization for consumer directed services. Each authorization for consumer directed services shall include the required elements for a referral (see Section 2.9.7.4.7 of this Agreement) including: authorized service, authorized units of service, including amount, frequency and duration, start and end dates, and service code.
  2.9.7.5.7   If initiation of consumer directed services does not begin within sixty (60) days from the date of the CONTRACTOR’s referral to the FEA, the FEA shall contact the CONTRACTOR regarding the cause of the delay. The CONTRACTOR shall determine the appropriate next steps, including but not limited to whether an extension is warranted or if the member is still interested in participating in consumer direction of HCBS.

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  2.9.7.5.8   Upon the scheduled start date of consumer directed services, the member’s care coordinator/care coordination team shall begin monitoring to ensure that services have been initiated and continue to be provided as authorized. This shall include ongoing monitoring via electronic visit verification to ensure that services are provided in accordance with the member’s plan of care, including the amount, frequency, duration and scope of each service, in accordance with the member’s service schedule. Upon the identification of any gaps in care, the member’s care coordinator/care coordination team shall contact the FEA who will be responsible for assisting the member or his/her representative as needed in activating the member’s back-up plan for consumer direction.
  2.9.7.5.9   Within five (5) business days of the scheduled start date of consumer directed services as specified in the authorization of consumer directed services a member of the care coordinator team shall contact the member or his/her representative to confirm that services are being provided and that the member’s needs are being met.
  2.9.7.5.10   On an ongoing basis, in addition to requirements specified above in 2.9.7.5.3 – 2.9.7.5.7 above:
  2.9.7.5.10.1   The CONTRACTOR shall develop and forward to the FEA a new authorization for consumer directed services when the following occur: a change in the number of service units, or the frequency or duration of service delivery; or a change in the services to be provided through consumer direction, including the provision of a new service through consumer direction or termination of a service through consumer direction.
  2.9.7.6   Worker Qualifications
  2.9.7.6.1   The FEA shall ensure that workers meet all requirements prior to the worker providing services. The FEA shall ensure that workers: meet all TennCare established requirements for providers of comparable, non-consumer directed services; pass a background check which includes criminal background check (including fingerprinting), or, as an alternative, a background check from a licensed private investigation company, verification that the person’s name does not appear on the State abuse registry, verification that the person’s name does not appear on the state and national sexual offender registries and licensure verification, as applicable; complete all required training, including the training specified in Section 2.9.7.7 of this Agreement; complete all required applications to become a TennCare provider; sign the TennCare provider agreement; and are assigned a Medicaid provider ID number.
  2.9.7.6.1.1   A member cannot waive a background check for a potential worker. The following findings shall disqualify a person from serving as a worker:
 
  2.9.7.6.1.1.1   Conviction of an offense involving physical, sexual or emotional abuse, neglect, financial exploitation or misuse of funds, misappropriation of property, theft from any person, violence against any person, or manufacture, sale, possession or distribution of any drug;

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  2.9.7.6.1.1.2   Entering of a plea of nolo contendere or when a jury verdict of guilty is rendered but adjudication of guilt is withheld with respect to a crime reasonably related to the nature of the position sought or held;
  2.9.7.6.1.1.3   Identification on the abuse registry;
 
  2.9.7.6.1.1.4   Identification on the state or national sexual offender registry;
  2.9.7.6.1.1.5   Failure to have a required license; and
 
  2.9.7.6.1.1.6   Refusal to cooperate with a background check.
 
  2.9.7.6.1.2   In certain instances a member may choose to hire a worker that fails a background check. Exceptions to disqualification may be granted at the member’s discretion and only if all of the following conditions are met:
  2.9.7.6.1.2.1   Offense is a misdemeanor;
 
  2.9.7.6.1.2.2   Offense occurred more than five (5) years ago;
 
  2.9.7.6.1.2.3   Offense is not related to physical or sexual or emotional abuse of another person;
 
  2.9.7.6.1.2.4   Offense does not involve violence against another person or the manufacture, sale, or distribution of drugs; and
 
  2.9.7.6.1.2.5   There is only one disqualifying offense.
  2.9.7.6.2   The FEA shall make the decision regarding exceptions to disqualification. In the event a member chooses to hire a worker that has failed a background check but has met all of the conditions for an exception to disqualification and the FEA has granted the exception, the FEA shall notify the care coordinator prior to initiation of services provided by that worker.
  2.9.7.6.3   Workers are not required to be contract providers. The CONTRACTOR shall not require a worker to sign a provider agreement or any other agreement not specified by TENNCARE.
 
  2.9.7.6.4   Members shall have the flexibility to hire persons with whom they have a close personal relationship to serve as a worker, such as a neighbor or a friend.
  2.9.7.6.5   Members may hire family members, excluding spouses, to serve as a worker. A family member shall not be reimbursed for a service that he/she would have otherwise provided without pay. The CONTRACTOR shall use the needs assessment process (Section 2.9.6.5) to assess the member’s available existing supports, including supports provided by family members.
  2.9.7.6.6   A member may have multiple workers or both a worker and a contract provider for a given service, in which case, there must be a set schedule which clearly defines when contract providers will be utilized. A member may elect to have a worker provide more than one service.

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  2.9.7.6.7   A member shall develop a service agreement with each worker. The service agreement template shall be developed by TENNCARE and shall include, at a minimum: the roles and responsibilities of the worker and the member; the worker’s schedule (as developed by the member and/or representative), including hours and days; the scope of each service, i.e., the specific tasks and functions the worker is to perform; the service rate; and the requested start date for services. The service agreement shall serve as the worker’s written confirmation of his/her commitment to initiate services on or before the date specified and to provide services in accordance with specified terms (including the tasks and functions to be performed and the schedule at which care is needed). If necessary, the FEA shall assist in this process. Service agreements shall be updated anytime there is a change in any of the terms or conditions specified in the agreement. Service agreements shall be signed by the new representative when there is a change in representatives.
  2.9.7.6.8   The service agreement shall also stipulate if a worker will provide one or more self- directed health care tasks, the specific task(s) to be performed, and the frequency of each self-directed health care task (see Section 2.7 3).
  2.9.7.6.9   The FEA shall ensure that a service agreement is in place for each worker prior to the worker providing services.
  2.9.7.6.10   A copy of each service agreement shall be provided to the member and/or representative. The FEA shall give a copy of the service agreement to the worker and shall maintain a copy for its files.
  2.9.7.6.11   A member may terminate a worker at any time if he/she feels that the worker is not adhering to the terms of the service agreement and/or is not providing quality services. If the FEA or care coordinator has concerns that a worker is unable to deliver appropriate care as prescribed in the service agreement and the plan of care, but the member and/or representative chooses to continue to employ the worker, the care coordinator shall note the concern and the member’s choice to continue using the worker in the member’s plan of care, and shall update the risk assessment and/or risk agreement as needed. The FEA and care coordinator shall collaborate to develop strategies to address identified issues and concerns. The FEA shall inform the member and/or representative of any potential risks associated with continuing to use the worker. The CONTRACTOR shall forward to TENNCARE for disposition, pursuant to TennCare policy, any cases in which the CONTRACTOR plans to disenroll the member from consumer direction because a care coordinator has determined that the health, safety and welfare of the member may be in jeopardy if the member continues to employ a worker but the member and/or representative does not want to terminate the worker. The CONTRACTOR and FEA shall abide by TENNCARE’s decision.
  2.9.7.6.12   A member shall have the flexibility to choose from a range of TENNCARE specified reimbursement levels for all eligible consumer directed HCBS, excluding companion care services which shall be reimbursed at the rate specified by TENNCARE.
  2.9.7.6.13   In order to receive payment for services rendered, all workers must:
  2.9.7.6.13.1   Submit to the member and the FEA planned work schedules two weeks in advance and when billing. The FEA shall input schedules into the EVV; and

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  2.9.7.6.13.2   Maintain and submit timesheets and documentation of service delivery (i.e., documentation of the tasks and functions performed during the provision of services), and any other documentation, as required, for units of service delivered; and
  2.9.7.6.13.3   Provide no more than forty (40) hours of services within a consecutive seven (7) day period, with the following exceptions:
  2.9.7.6.13.3.1   The worker provides companion care services; or
  2.9.7.6.13.3.2   The worker serves as a back-up worker during this period, in which case payment shall be at the established rate, with no overtime pay, in accordance with applicable labor law. The FEA shall monitor the frequency of instances in which a worker provides more than forty (40) hours of service within a consecutive seven day period for this reason, and shall work with the member and/or representative to develop an adequate supply of reliable workers.
  2.9.7.6.13.4   The FEA shall enter worker schedules into the EVV, but may delegate this responsibility to the member and/or representative when appropriate.
  2.9.7.7   Training
  2.9.7.7.1   The CONTRACTOR shall require all members electing to enroll in consumer direction of HCBS and/or their representatives to receive relevant training prior to service initiation. The FEA shall be responsible for providing or arranging for the training. When training is not directly provided by the FEA, the FEA shall validate completion of training.
  2.9.7.7.2   At a minimum, consumer direction training for members and/or representatives shall address the following issues:
  2.9.7.7.2.1   Understanding the role of members and representatives in consumer direction;
 
  2.9.7.7.2.2   Understanding the role of the care coordinator and the FEA;
 
  2.9.7.7.2.3   Selecting workers;
 
  2.9.7.7.2.4   Abuse and neglect identification and reporting;
 
  2.9.7.7.2.5   Being an employer, evaluating worker performance and managing employees;
 
  2.9.7.7.2.6   Fraud and abuse;
 
  2.9.7.7.2.7   Performing administrative tasks such as reviewing and approving time sheets; and
 
  2.9.7.7.2.8   Scheduling workers and back-up planning.

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  2.9.7.7.3   Ongoing training shall be provided by the FEA to members and/or representatives upon request and/or if a care coordinator or FEA, through monitoring, determines that additional training is warranted.
  2.9.7.7.4   The FEA shall be responsible for providing or arranging for the training of all workers prior to service initiation. When training is not directly provided by the FEA, the FEA shall validate completion of training. At a minimum, training shall consist of the following required elements:
  2.9.7.7.4.1   Overview of the CHOICES program and consumer direction of HCBS;
 
  2.9.7.7.4.2   Caring for elderly and disabled populations;
 
  2.9.7.7.4.3   Abuse and neglect identification and reporting;
 
  2.9.7.7.4.4   CPR and first aid certification;
 
  2.9.7.7.4.5   Critical incident reporting;
 
  2.9.7.7.4.6   Submission of timesheets, required documentation and withholdings;
 
  2.9.7.7.4.7   EVV system functionality, requirements and how to use; and
 
  2.9.7.7.4.8   As appropriate, administration of self-directed health care task(s).
  2.9.7.7.5   The member or representative, with assistance of the FEA, shall determine to what extent the member or representative shall be involved in the above-specified training, except that the member or representative must direct training regarding the administration of self-directed health care tasks.
  2.9.7.7.6   In addition to the training noted above in 2.9.7.7.4.1 – 2.9.7.7.4.8, the member shall provide training to the worker regarding individualized service needs and preference.
  2.9.7.7.7   The FEA shall verify that workers have successfully completed all required training prior to service initiation and payment for services.
  2.9.7.7.8   Ongoing, the FEA shall ensure that workers maintain CPR and first aid certification and receive required refresher training as a condition of continued employment and shall arrange for the appropriate training. Additional training components may be provided to a worker to address issues identified by the FEA, care coordinator, member and/or the representative or at the request of the worker.
  2.9.7.7.9   Refresher training may be provided more frequently if determined necessary by the FEA, care coordinator, member and/or representative or at the request of the worker.
  2.9.7.8   Monitoring
  2.9.7.8.1   The FEA shall conduct semi-annual face-to-face visits in the member’s place of residence and conduct monthly phone contacts. These visits and contacts shall supplement and not supplant the minimum care coordinator contacts. The FEA shall use these visits to monitor the quality of service delivery including:

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  2.9.7.8.1.1   Identifying any service delivery issues;
 
  2.9.7.8.1.2   Determining the adequacy and appropriateness of documentation of service delivery; and
 
  2.9.7.8.1.3   Determining the efficacy of back-up plans and processes.
 
  2.9.7.8.2   At a minimum, the FEA shall conduct the following additional monitoring activities:
 
  2.9.7.8.2.1   Quarterly reviews of expenditures for each member; and
  2.9.7.8.2.2   Monthly reviews of hours billed for services across all members, by each worker.
  2.9.7.8.3   The CONTRACTOR shall monitor a member’s participation in consumer direction of HCBS to determine, at a minimum, the success and the viability of the service delivery model for the member. The CONTRACTOR shall note any patterns, such as frequent turnover of representatives and changing between consumer direction of HCBS and contract providers that may warrant intervention by the CONTRACTOR. The CONTRACTOR may submit a request to TENNCARE, pursuant to TennCare policy, to involuntarily withdraw the member from consumer direction of HCBS if the CONTRACTOR has concerns about its ability to protect the health, safety and welfare of the member (see Section 2.9.7.8.5).
  2.9.7.8.4   If at any time the care coordinator or FEA suspects abuse or neglect on the part of the representative or worker, the care coordinator and/or FEA shall report the allegations to the CONTRACTOR. The CONTRACTOR shall report the representative and/or worker to APS. The representative and/or worker shall immediately be released from his/her duties until the APS investigation is complete. The care coordinator shall work with the member to find a new representative, and the FEA shall work with the member to find a suitable replacement worker. If the allegations are substantiated as a result of the APS investigation, the representative and/or worker shall no longer be allowed to participate in the CHOICES program in any capacity.
  2.9.7.8.5   In the event the CONTRACTOR believes that it cannot safely and effectively serve the member in the community, the care coordinator, with the assistance of and input from the FEA, shall review with the member the previously developed risk agreement and update it to ensure that any additional identified risks are incorporated and measures are identified to mitigate risks. The representative (if applicable) shall participate in the process. The updated risk assessment shall be signed by the member or representative and the care coordinator. A copy shall be given to the member or representative. The member’s care coordinator/care coordination team and the FEA shall file a copy in the member’s files. If the CONTRACTOR does not believe the member can be safely and effectively served in the community directing his/her services, the CONTRACTOR may request to involuntarily withdraw the member from consumer direction of HCBS, pursuant to TennCare policy (see Section 2.9.7.9 below).

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  2.9.7.9   Withdrawal from Consumer Direction of HCBS
  2.9.7.9.1   A member may voluntarily withdraw from consumer direction of HCBS at any time. The member and/or representative shall notify the care coordinator as soon as he/she determines that he/she is no longer interested in participating in consumer direction of HCBS.
  2.9.7.9.2   Upon receipt of a member’s request to withdraw from consumer direction of HCBS, the CONTRACTOR shall conduct a face-to-face visit and update the member’s plan of care, as appropriate, to initiate the process to transition the member to contract providers.
  2.9.7.9.3   The CONTRACTOR may initiate involuntary withdrawal of a member from consumer direction of HCBS:
  2.9.7.9.3.1   If a member’s representative fails to perform in accordance with the terms of the representative agreement and the health, safety and welfare of the member is at risk, and the member wants to continue to use the representative.
  2.9.7.9.3.2   If a member has consistently demonstrated that he/she is unable to manage, with sufficient supports (including appointment of a representative) his/her services and the care coordinator or FEA has identified health, safety and/or welfare issues.
  2.9.7.9.3.3   A care coordinator has determined that the health, safety and welfare of the member may be in jeopardy if the member continues to employ a worker but the member and/or representative does not want to terminate the worker.
  2.9.7.9.3.4   Other significant concerns regarding the member’s participation in consumer direction which jeopardize the health, safety or welfare of the member.
  2.9.7.9.4   The CONTRACTOR shall forward to TENNCARE, pursuant to TennCare policy, a request to involuntarily withdraw a member from consumer direction of HCBS. The request shall include the reasons for withdrawing the member and the measures taken by the CONTRACTOR and/or the FEA to address identified issues.
  2.9.7.9.5   If TENNCARE approves the CONTRACTOR’s request, the CONTRACTOR shall notify the member in accordance with TennCare rules and regulations, and the member shall have the right to appeal the determination (see Section 2.19.3.1 2of this Agreement). Upon notification or the resolution of a timely filed appeal, the CONTRACTOR, in conjunction with the FEA, shall facilitate a seamless transition from workers to contract providers, with no interruptions or gaps in services.
  2.9.7.9.6   Voluntary or involuntary withdrawal of a member from consumer direction of HCBS shall not affect a member’s eligibility for long-term care services or enrollment in CHOICES.
  2.9.7.9.7   Members who have been involuntarily withdrawn may request to be reinstated in consumer direction of HCBS. The care coordinator shall work with the FEA to ensure that the issues previously identified as reasons for withdrawal have been adequately addressed prior to reinstatement. All members shall be required to

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      participate in consumer direction training programs prior to re-instatement in consumer direction of HCBS.
2.9.8 Coordination and Collaboration for Members with Behavioral Health Needs
  2.9.8.1   General
      As provided in Section 2.6.1 of this Agreement, the CONTRACTOR shall be responsible for providing a full continuum of physical health, behavioral health, and long-term care services. The CONTRACTOR shall also be responsible for ensuring continuity and coordination between covered physical health, behavioral health, and long-term care services and ensuring collaboration between physical health, behavioral health, and long-term care providers. The CONTRACTOR shall develop policies and procedures that address key elements in meeting this requirement. These elements include, but are not limited to, screening for behavioral health needs (including the screening tool), referral to physical health, behavioral health, and long-term care providers, exchange of information, confidentiality, assessment, treatment plan and plan of care development and implementation, collaboration, MCO case management, care coordination (for CHOICES members) and disease management, provider training, and monitoring implementation and outcomes.
  2.9.8.2   Subcontracting for Behavioral Health Services
      If the CONTRACTOR subcontracts for the provision of behavioral health services, the CONTRACTOR shall develop and implement a written agreement with the subcontractor regarding the coordination of services provided by the CONTRACTOR and those provided by the subcontractor. The agreement shall address the responsibilities of the CONTRACTOR and the subcontractor regarding, at a minimum, the items identified in Section 2.9.8.2 as well as prior authorization, claims payment, claims resolution, contract disputes, and reporting. The subcontract shall comply with all of the requirements regarding subcontracts included in Section 2.26 of this Agreement.
  2.9.8.3   Screening for Behavioral Health Needs
  2.9.8.3.1   The CONTRACTOR shall ensure that the need for behavioral health services is systematically identified by and addressed by the member’s PCP at the earliest possible time following initial enrollment of the member in the CONTRACTOR’s MCO or after the onset of a condition requiring mental health and/or substance abuse treatment.
  2.9.8.3.2   The CONTRACTOR shall encourage PCPs and other providers to use a screening tool prior approved in writing by the State as well as other mechanisms to facilitate early identification of behavioral health needs.
  2.9.8.3.3   As part of the care coordination process (see Section 2.9.6), the CONTRACTOR shall ensure that behavioral health needs of CHOICES members are identified and addressed.

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  2.9.8.4   Referrals to Behavioral Health Providers
      The CONTRACTOR shall ensure through screening that members with a need for behavioral health services, particularly members with SED/SPMI are appropriately referred to behavioral health providers. The CONTRACTOR shall develop provider education and training materials to ensure that physical health and long-term care providers know when and how to refer members who need specialty behavioral health services. This shall include education about behavioral health services, including the recovery process and resilience for children. The CONTRACTOR shall develop a referral process to be used by its providers, including what information must be exchanged and when to share this information, as well as notification to the member’s care coordinator.
  2.9.8.5   Referrals to PCPs
      The CONTRACTOR shall ensure that members with both physical health and behavioral health needs are appropriately referred to their PCPs for treatment of their physical health needs. The CONTRACTOR shall develop provider education and training materials to ensure that behavioral health providers know when and how to refer members who need physical health services. The CONTRACTOR shall develop a referral process to be used by its providers. The referral process shall include providing a copy of the physical health consultation and results to the behavioral health provider.
  2.9.8.6   Referrals to CHOICES
      The CONTRACTOR shall ensure that members with both long-term care and behavioral health needs are referred to the CONTRACTOR for CHOICES intake (see Section 2.9.6.3). The CONTRACTOR shall develop provider education and training materials to ensure that behavioral health providers know when and how to refer members who need long-term care services to the CONTRACTOR.
  2.9.8.7   Behavioral Health Assessment and Treatment Plan
      The CONTRACTOR’s policies and procedures shall identify the role of physical health and behavioral health providers in assessing a member’s behavioral health needs and developing an individualized treatment plan. For members with chronic physical conditions that require ongoing treatment who also have behavioral health needs, the CONTRACTOR shall encourage participation of both the member’s physical health provider (PCP or specialist) and behavioral health provider in the assessment and individualized treatment plan development process as well as the ongoing provision of services. For CHOICES members in Groups 2 and 3 with behavioral health needs, the member’s care coordinator shall encourage participation of the member’s behavioral health provider in the care planning process and shall incorporate relevant information from the member’s behavioral health treatment plan (see Section 2.7.2.1.4) in the member’s plan of care (see Section 2.9.6.6).
  2.9.8.8   MCO Case Management, Disease Management, and CHOICES Care Coordination
      The CONTRACTOR shall use its MCO case management, disease management, and CHOICES care coordination programs (see Sections 2.9.5, 2.8, and 2.9.6) to support

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      the continuity and coordination of covered physical health, behavioral health, and long-term care services and the collaboration between physical health, behavioral health, and long-term care providers. The CONTRACTOR has the option to allow members, e.g., members who have been determined to be high risk based on disease management stratification (see Section 2.8.3), to be enrolled in both a disease management program and MCO case management. For CHOICES members, MCO case management and/or disease management activities shall be integrated with the care coordination process (see Sections 2.9.5.4, and 2.9.6.1.8).
  2.9.8.9   Monitoring
      The CONTRACTOR shall evaluate and monitor the effectiveness of its policies and procedures regarding the continuity and coordination of covered physical, behavioral health, and long-term care services and collaboration between physical health, behavioral health, and long-term care providers. This shall include, but not be limited to, an assessment of the appropriateness of the diagnosis, treatment, and referral of behavioral health disorders commonly seen by PCPs; an evaluation of the appropriateness of psychopharmacological medication; and analysis of data regarding access to appropriate services. Based on these monitoring activities, the CONTRACTOR shall develop and implement interventions to improve continuity, coordination, and collaboration for physical health, behavioral health, and long-term care services.
2.9.9 Coordination and Collaboration Among Behavioral Health Providers
  2.9.9.1   The CONTRACTOR shall ensure communication and coordination between mental health providers and substance abuse providers, including:
  2.9.9.1.1   Assignment of a responsible party to ensure communication and coordination occur;
  2.9.9.1.2   Determination of the method of mental health screening to be completed by substance abuse service providers; screening and assessment tools to be designated by TENNCARE;
  2.9.9.1.3   Determination of the method of substance abuse screening to be completed by mental health service providers; screening and assessment tools to be designated by TENNCARE;
  2.9.9.1.4   Description of how treatment plans will be coordinated between behavioral health service providers; and
  2.9.9.1.5   Assessment of cross training of behavioral health providers: mental health providers being trained on substance abuse issues and substance abuse providers being trained on mental health issues.
  2.9.9.2   The CONTRACTOR shall ensure coordination between the children and adolescent service delivery system as they transition into the adult mental health service delivery system, through such activities as communicating treatment plans and exchange of information.

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  2.9.9.3   The CONTRACTOR shall coordinate inpatient and community services, including the following requirements related to hospital admission and discharge:
 
  2.9.9.3.1   The outpatient provider shall be involved in the admissions process when possible; if the outpatient provider is not involved, the outpatient provider shall be notified promptly of the member’s hospital admission;
  2.9.9.3.2   Psychiatric hospital and residential treatment facility discharges shall not occur without a discharge plan in which the member has participated (an outpatient visit shall be scheduled before discharge, which ensures access to proper provider/medication follow-up; also, an appropriate placement or housing site shall be secured prior to discharge);
  2.9.9.3.3   An evaluation shall be performed prior to discharge to determine if mental health case management services are medically necessary. Once deemed medically necessary, the mental health case manager shall be involved in discharge planning; if there is no mental health case manager, then the outpatient provider shall be involved; and
  2.9.9.3.4   A procedure to ensure continuity of care regarding medication shall be developed and implemented.
  2.9.9.4   The CONTRACTOR shall identify and develop community alternatives to inpatient hospitalization for those members who are receiving inpatient psychiatric facility services who could leave the facility if appropriate community or residential care alternatives were available in the community. In the event the CONTRACTOR does not provide appropriate community alternatives, the CONTRACTOR shall remain financially responsible for the continued inpatient care of these individuals.
  2.9.9.5   The CONTRACTOR is responsible for providing a discharge plan as outlined in Section 2.9.9.3.2.
2.9.10 Coordination of Pharmacy Services
  2.9.10.1   Except as provided in Section 2.6.1.3, the CONTRACTOR is not responsible for the provision and payment of pharmacy benefits; TENNCARE contracts with a pharmacy benefits manager (PBM) to provide these services. However, the CONTRACTOR shall coordinate with the PBM as necessary to ensure that members receive appropriate pharmacy services without interruption. The CONTRACTOR shall monitor and manage its contract providers as it relates to prescribing patterns and its members as it relates to utilization of prescription drugs. The CONTRACTOR shall participate in regularly scheduled meetings with the PBM and TENNCARE to discuss operational and programmatic issues.
  2.9.10.2   The CONTRACTOR shall accept and maintain prescription drug data from TENNCARE or its PBM.
  2.9.10.3   The CONTRACTOR shall monitor and manage members by, at a minimum, conducting the activities as described below:

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  2.9.10.3.1   Analyzing prescription drug data and/or reports provided by the PBM or TENNCARE to identify high-utilizers and other members who inappropriately use pharmacy services and assign them to MCO case management and/or disease management programs and/or refer them to CHOICES intake (see Section 2.9.6) as appropriate; if a CHOICES member is identified as a high-utilizer or as inappropriately using pharmacy services, relevant prescription drug data and/or reports for the member shall be provided to the member’s care coordinator, and the care coordinator shall take appropriate next steps, which may include coordination with the member’s PCP;
  2.9.10.3.2   Analyzing prescription drug data and/or reports provided by the PBM to identify potential pharmacy lock-in candidates and referring them to TENNCARE; and
  2.9.10.3.3   Regularly providing information to members about appropriate prescription drug usage. At a minimum, this information shall be included in the Member Handbook and in at least two (2) quarterly member newsletters within a twelve (12) month period.
  2.9.10.4   The CONTRACTOR shall monitor and manage providers’ prescription patterns by, at a minimum, conducting the activities described below:
  2.9.10.4.1   Collaborating with the PBM to educate the MCO’s contract providers regarding compliance with the State’s preferred drug list (PDL) and appropriate prescribing practices; and
  2.9.10.4.2   Intervening with contract providers whose prescribing practices appear to be operating outside industry or peer norms as defined by TENNCARE, are noncompliant as it relates to adherence to the PDL and/or generic prescribing patterns, and/or who are failing to follow required prior authorization processes and procedures. The goal of these interventions will be to improve prescribing practices among the identified contract providers, as appropriate. Interventions shall be personal and one-on-one.
  2.9.10.5   At any time, upon request from TENNCARE, the CONTRACTOR shall provide assistance in educating, monitoring and intervening with providers. For example, TENNCARE may require assistance in monitoring and intervening with providers regarding prescribing patterns for narcotics.
2.9.11 Coordination of Dental Benefits
  2.9.11.1   General
  2.9.11.1.1   The CONTRACTOR is not responsible for the provision and payment of dental benefits; TENNCARE contracts with a dental benefits manager (DBM) to provide these services.
  2.9.11.1.2   As provided in Section 2.6.1.3, the CONTRACTOR is responsible for transportation to and from dental services as well as the facility, medical and anesthesia services related to medically necessary and approved dental services that are not provided by a dentist or in a dentist’s office.

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  2.9.11.1.3   The CONTRACTOR may require prior authorization for services related to dental services including the facility, anesthesia, and/or medical services related to the dental service. However, the CONTRACTOR may waive authorization of said services based upon authorization of the dental services by the dental benefits manager. The CONTRACTOR shall approve and arrange transportation to and from dental services in accordance with this Agreement, including but not limited to Attachment XI.
  2.9.11.2   Services and Responsibilities
 
      The CONTRACTOR shall coordinate with the DBM for dental services. Coordination of dental services, at a minimum, includes establishing processes for:
  2.9.11.2.1   Means for referral that ensures immediate access for emergency care and provision of urgent and routine care according to TennCare guidelines for specialty care (see Attachment III);
  2.9.11.2.2   Means for the transfer of information (to include items before and after the visit);
 
  2.9.11.2.3   Maintenance of confidentiality;
  2.9.11.2.4   Resolving disputes related to prior authorizations and claims and payment issues; and
 
  2.9.11.2.5   Cooperation with the DBM regarding training activities provided by the DBM.
  2.9.11.3   Operating Principles
      Coordinating the delivery of dental services to TennCare members is the primary responsibility of the DBM. However, the CONTRACTOR shall provide coordination assistance and shall be responsible for communicating the DBM provider services, provider relations, and/or claim coordinator contact information to all of its contract providers. With respect to specific member issues, the CONTRACTOR shall work with the DBM coordinator towards a resolution. Should systemic issues arise, the CONTRACTOR shall meet and resolve the issues with the DBM. In the event that such issues cannot be resolved, the MCO and the DBM shall meet with TENNCARE to reach final resolution of matters involved. Final resolution of system issues shall occur within ninety (90) calendar days from referral to TENNCARE.
  2.9.11.4   Resolution of Requests for Prior Authorization
  2.9.11.4.1   The CONTRACTOR agrees, and recognizes that the DBM has agreed through its contractual arrangement with the State, that any dispute concerning which party should respond to a request for prior authorization shall not cause a denial, delay, reduction, termination or suspension of any appropriate service to a TennCare enrollee. The CONTRACTOR shall require that its DBM care coordinators will, in addition to their responsibilities for DBM care coordination, deal with issues related to requests for prior authorization that require coordination between the DBM and the CONTRACTOR. The CONTRACTOR shall provide the DBM with a list of its DBM care coordinators and telephone number(s) at which each DBM care coordinator may be contacted. When the CONTRACTOR receives a request for prior authorization from a provider for a member and the CONTRACTOR believes the service is the

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      responsibility of the DBM, the CONTRACTOR’s DBM care coordinator shall contact the DBM’s care coordinator by the next business day after receiving the request for prior authorization. The DBM care coordinator shall also contact the member and/or member’s provider. For routine requests contact to the member or member’s provider shall be made within fourteen (14) days or less of the provider’s request for prior authorization and shall comply with all applicable consent decrees and court orders and TennCare rules and regulations. For urgent requests, contact shall be made immediately after receiving the request for prior authorization.
  2.9.11.4.2   The CONTRACTOR shall assign staff members to serve on a coordination committee with DBM staff members. This committee shall be responsible for addressing all issues of dental care coordination. The committee will review disputes regarding clinical care and provide a clinical resolution to the dispute, subject to the terms of this Agreement. The CONTRACTOR and the DBM shall attempt in good faith to resolve any dispute and communicate the decision to the provider requesting prior authorization of a service. In the event the CONTRACTOR and the DBM cannot agree within ten (10) calendar days of the provider’s request for prior authorization, the party who first received the request from the provider shall be responsible for prior authorization and payment to the contract provider within the time frames designated by TENNCARE. The CONTRACTOR and the DBM are responsible for enforcing hold harmless protection for the member. The CONTRACTOR shall ensure that any response to a request for authorization shall not exceed fourteen (14) calendar days and shall comply with all applicable consent decrees and court orders and TennCare rules and regulations.
  2.9.11.5   Claim Resolution Processes
  2.9.11.5.1   The CONTRACTOR shall designate one or more claims coordinators to deal with issues related to claims and payment issues that require coordination between the DBM and the CONTRACTOR. The CONTRACTOR agrees and recognizes that the DBM has agreed through its contractual arrangement with the State, to also designate one or more claims coordinators to deal with issues related to claims and payment issues that require coordination between the DBM and the CONTRACTOR. The CONTRACTOR shall provide the DBM and TennCare, with a list of its claims coordinators and telephone number(s) at which each claims coordinator may be contacted.
  2.9.11.5.2   When the CONTRACTOR receives a disputed claim for payment from a provider for a member and believes care is the responsibility of the DBM, the CONTRACTOR’s claims coordinators shall contact the DBM’s claims coordinators within four (4) calendar days of receiving such claim for payment. If the CONTRACTOR’s claims coordinator is unable to reach agreement with the DBM’s claims coordinators on which party is responsible for payment of the claim, the claim shall be referred to the Claims Coordination Committee (described below) for review.
  2.9.11.5.3   The CONTRACTOR shall assign claims coordinators and other representatives, as needed, to a joint CONTRACTOR/DBM Claims Coordination Committee. The number of members serving on the Claims Coordination Committee shall be determined within ten (10) calendar days of the execution of this Agreement by the mutual agreement of the DBM and MCO. The CONTRACTOR shall, at a minimum, assign two (2) representatives to the committee. The make-up of the committee may

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      be revisited from time to time during the term of this Agreement. The Claims Coordination Committee shall review any disputes and negotiate responsibility between the CONTRACTOR and the DBM. Unless otherwise agreed, such meeting shall take place within ten (10) calendar days of receipt of the initial disputed claim or request from the provider. If resolution of the claim results in the party who assumed responsibility for authorization and payment having no liability, the other party shall reimburse and abide by the prior decisions of that party. Reimbursement shall be made within ten (10) calendar days of the Claims Coordination Committee’s decision.
  2.9.11.5.4   If the Claims Coordination Committee cannot reach an agreement as to the proper division of financial responsibility within ten (10) calendar days of the initial referral to the Claims Coordination Committee, said claim shall be referred to both the CONTRACTOR’s and the DBM’s CEO or the CEO’s designee, for resolution immediately. A meeting shall be held among the CEOs or their designee(s) as soon as possible, but not longer than ten (10) calendar days after the meeting of the Claims Coordination Committee.
  2.9.11.5.5   If the meeting between the CEOs, or their designee(s), of the DBM and MCO does not successfully resolve the dispute within ten (10) calendar days, the parties shall, within fourteen (14) calendar days of the meeting, submit a Request for Resolution of the dispute to the State or the State’s designee for a decision on responsibility.
  2.9.11.5.6   The process before the submission of a Request for Resolution, as described above, shall be completed within thirty (30) calendar days of receiving the claim for payment. In the event the parties cannot agree within thirty (30) calendar days of receiving the claim for payment, the MCO and the DBM shall be responsible for enforcing hold harmless protections for the member and the party who first received the request or claim from the provider shall be responsible for authorization and payment to the provider in accordance with the requirements of the MCO’s or DBM’s respective Agreement/contract with the State of Tennessee. Moreover, the party that first received the request or claim from the provider shall also make written request of all requisite documentation for payment and shall provide written reasons for any denial.
  2.9.11.5.7   The Request for Resolution shall contain a concise description of the facts regarding the dispute, the applicable Agreement/contract provisions, and the position of the party making the request. A copy of the Request for Resolution shall also be delivered to the other party. The other party shall then submit a Response to the Request for Resolution within fifteen (15) calendar days of the date of the Request for Resolution. The Response shall contain the same information required of the Request for Resolution. Failure to timely file a Response or obtain an extension from the State shall be deemed a waiver of any objections to the Request for Resolution.
  2.9.11.5.8   The State or its designee shall make a decision in writing regarding who is responsible for the payment of services within ten (10) calendar days of the receipt of the required information (“Decision”). The Decision may reflect a split payment responsibility that designates specific proportions to be paid by the MCO and the DBM. The Decision shall be determined solely by the State or its designee based on specific circumstances regarding each individual case. Within five (5) business days of receipt of the Decision, the non-successful party shall reimburse any payments

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      made by the successful party for the services. The non-successful party shall also pay to the State, within thirty (30) calendar days of the Decision, an administrative fee equal to ten percent (10%) of the value of the claims paid, not to exceed one- thousand dollars ($1,000), for each Request for Resolution. The amount of the DBM’s or MCO’s payment responsibility shall be contained in the State’s Decision. These payments may be made with reservation of rights regarding any judicial resolution. If a party fails to pay the State for the party’s payment responsibility as described in this Section, Section 2.9.11.5.8, within thirty (30) calendar days of the date of the State’s Decision, the State may deduct amounts of the payment responsibility from any current or future amount owed the party by the State.
  2.9.11.6   Denial, Delay, Reduction, Termination or Suspension
      The CONTRACTOR agrees that any claims payment dispute or request for authorization shall not cause a denial, delay, reduction, termination or suspension of any appropriate services to a TennCare member. In the event there is a claim for emergency services, the party receiving a request for authorization to treat any member shall insure that the member is treated immediately and payment for the claim shall be approved or disapproved based on the definition of emergency services specified in this Agreement.
  2.9.11.7   Emergencies
      Prior authorization shall not be required for emergency services prior to stabilization.
  2.9.11.8   Claims Processing Requirements
      All claims shall be processed in accordance with the requirements of the MCO’s and DBM’s respective Agreements/contracts with the State of Tennessee.
  2.9.11.9   Appeal of Decision
      Appeal of any Decision shall be to a court or commission of competent jurisdiction and shall not constitute a procedure under the Administrative Procedure Act, TCA 4- 5-20 1 et seq. Exhaustion of the above-described process shall be required before filing of any claim or lawsuit on issues covered by this Section, Section 2.9.11.9
  2.9.11.10   Duties and Obligations
      The existence of any dispute under this Agreement shall in no way affect the duty of the CONTRACTOR and the DBM to continue to perform their respective obligations, including their obligations established in their respective Agreements/contracts with the State pending resolution of the dispute under this Section, Section 2.9.11.10. In accordance with TCA 56-32-126(b), a provider may elect to resolve the claims payment dispute through independent review.
  2.9.11.11   Confidentiality
  2.9.11.11.1   The CONTRACTOR agrees, and recognizes that the DBM has agreed through its contractual arrangement with the State, to cooperate with the State to develop confidentiality guidelines that (1) meet state, federal, and other regulatory

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      requirements; (2) meet the requirements of the professions or facilities providing care and maintaining records; and (3) meet both DBM and MCO standards. These standards shall apply to both DBM’s and MCO’s providers and staff. If the CONTRACTOR or DBM believes that the standards require updating, or operational changes are needed to enforce the standards, the CONTRACTOR shall meet with the DBM to resolve these issues. Such standards shall provide for the exchange of confidential e-mails to ensure the privacy of the members.
  2.9.11.11.2   The DBM and MCO shall ensure all materials and information directly or indirectly identifying any current or former member which is provided to or obtained by or through the MCO’s or DBM’s performance of this Agreement, whether verbal, written, tape, or otherwise, shall be maintained in accordance with the standards of confidentiality of TCA 33-4-22, Section 4.33 of this Agreement, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and, unless required by applicable law, shall not be disclosed except in accordance with those requirements or to TENNCARE, and CMS, or their designees. Nothing stated herein shall prohibit the disclosure of information in summary, statistical, or other form that does not identify any current or former member or potential member.
  2.9.11.12   Access to Service
      The CONTRACTOR agrees and recognizes that the DBM has agreed through its contractual arrangement with the State, to establish methods of referral which ensure immediate access to emergency care and the provision of urgent and routine care in accordance with TennCare guidelines.
2.9.12 Coordination with Medicare
  2.9.12.1   The CONTRACTOR is responsible for providing medically necessary covered services to members who are also eligible for Medicare if the service is not covered by Medicare.
  2.9.12.2   The CONTRACTOR shall ensure that services covered and provided pursuant to this Agreement are delivered without charge to members who are dually eligible for Medicare and Medicaid services.
  2.9.12.3   The CONTRACTOR shall coordinate with Medicare payers, Medicare Advantage plans, and Medicare providers as appropriate to coordinate the care and benefits of members who are also eligible for Medicare.

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2.9.13 ICF/MR Services and Alternatives to ICF/MR Services
  2.9.13.1   The CONTRACTOR is not responsible for services in an Intermediate Care Facility for the Mentally Retarded (ICF/MR) or for services provided through Home and Community Based Services (HCBS) waivers as an alternative to ICF/MR services (hereinafter referred to as “HCBS MR waiver”). However, to the extent that services available to a member through a HCBS MR waiver are also covered services pursuant to this Agreement, the CONTRACTOR shall be responsible for providing all medically necessary covered services. HCBS MR waiver services may supplement, but not supplant, medically necessary covered services. ICF/MR services and HCBS MR waiver services shall be provided to qualified members as described in TennCare rules and regulations through contracts between TENNCARE and appropriate providers.
  2.9.13.2   The CONTRACTOR is responsible for covered services for members residing in an ICF/MR or enrolled in a HCBS MR waiver. For members residing in an ICF/MR, the CONTRACTOR is responsible for providing covered services that are not included in the per diem reimbursement for institutional services (e.g., prosthetics, some items of durable medical equipment, non-emergency ambulance transportation, and non- emergency transportation). Except as provided below for NEMT, for members enrolled in a HCBS MR waiver, the CONTRACTOR shall provide all medically necessary covered services, including covered services that may also be provided through the HCBS MR waiver. The HCBS MR waiver is the payor of last resort. However, the CONTRACTOR is not responsible for providing non-emergency medical transportation (NEMT) to any service that is being provided to the member through the HCBS MR waiver.
  2.9.13.3   The CONTRACTOR shall coordinate the provision of covered services with services provided by ICF/MR and HCBS MR waiver providers to minimize disruption and duplication of services.
2.9.14 Inter-Agency Coordination
      The CONTRACTOR shall coordinate with other state and local departments and agencies to ensure that coordinated care is provided to members. This includes, but is not limited to, coordination with:
  2.9.14.1   Tennessee Department of Mental Health and Developmental Disabilities (TDMHDD) for the purpose of interfacing with and assuring continuity of care and for coordination of specialized services in accordance with federal PASRR requirements;
  2.9.14.2   Tennessee Department of Children’s Services (DCS) for the purpose of interfacing with and assuring continuity of care;
 
  2.9.14.3   Tennessee Department of Health (DOH), for the purposes of establishing and maintaining relationships with member groups and health service providers;
 
  2.9.14.4   Tennessee Department of Human Services (DHS) and DCS Protective Services Section, for the purposes of reporting and cooperating in the investigation of abuse and neglect;

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  2.9.14.5   The Division of Mental Retardation Services (DMRS), for the purposes of interfacing with and assuring continuity of care and for coordination of specialized services in accordance with federal PASRR requirements;
  2.9.14.6   Tennessee Department of Education (DOE) and local education agencies for the purposes of coordinating educational services in compliance with the requirements of Individuals with Disabilities Education Act (IDEA) and to ensure school-based services for students with special needs are provided;
  2.9.14.7   Area Agencies on Aging and Disability (AAADs) regarding intake of members new to both TennCare and CHOICES, assisting CHOICES members in Groups 2 and 3 with the TennCare eligibility redetermination process, and facilitating the transition of members during CHOICES implementation and when members are moving to a Grand Region where CHOICES has not yet been implemented;
  2.9.14.8   Tennessee Commission on Aging and Disability (TCAD) regarding TCAD’s role in monitoring the performance of the AAADs in conducting SPOE functions;
  2.9.14.8.1   The CONTRACTOR is responsible for the delivery of medically necessary covered services to school-aged children. MCOs are encouraged to work with school-based providers to manage the care of students with special health care needs. The State has implemented a process, referred to as TENNderCARE Connection, to facilitate notification of MCOs when a school-aged child enrolled in TennCare has an Individualized Education Plan (IEP) that identifies a need for medical services. In such cases, the school is responsible for obtaining parental consent to share the IEP with the MCO and for subsequently sending a copy of the parental consent and IEP to the MCO. The school is also responsible for clearly delineating the services on the IEP that the MCOs are to consider for payment. If a school-aged member, needing medical services, is identified by the CONTRACTOR by another means, the CONTRACTOR shall request the IEP from the appropriate school system.
  2.9.14.8.2   The CONTRACTOR shall designate a contact person to whom correspondence concerning children with medical services included in their IEPs will be directed. After receipt of an IEP, the CONTRACTOR shall:
  2.9.14.8.2.1   Either accept the IEP as indication of a medical problem and treat the IEP as a request for service or assist in making an appointment to have the child evaluated by the child’s PCP or another contract provider. If the CONTRACTOR does not accept the documentation provided with the IEP as indication of a medical problem, the CONTRACTOR shall have the child re-evaluated in order to make a decision about the appropriateness of the requested service.
  2.9.14.8.2.2   Send a copy of the IEP and any related information (e.g. action taken by the MCO in response to receipt of the IEP, action the MCO expects the PCP to take) to the PCP.
  2.9.14.8.2.3   Notify the designated school contact of the ultimate disposition of the request (e.g. what services have been approved for the child, what arrangements have been made for service delivery) within 14 days of the CONTRACTOR’s receipt of the IEP.

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  2.9.14.9   Local law enforcement agencies and hospital emergency rooms for the purposes of crisis service provider relationships, and the transportation of individuals certified for further assessment for emergency psychiatric hospitalization.
12. Section 2.11 shall be deleted in its entirety and replaced with the following:
2.11 PROVIDER NETWORK
2.11.1 General Provisions
  2.11.1.1   The CONTRACTOR shall provide or ensure the provision of all covered services specified in Section 2.6.1 of this Agreement. Accessibility of covered services, including geographic access and appointments and wait times shall be in accordance with the access standards in Attachment III, the Specialty Network Standards in Attachment IV, the Access and Availability for Behavioral Health Services in Attachment V and the requirements herein. These minimum requirements shall not release the CONTRACTOR from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members, whether specified above or not.
  2.11.1.2   The CONTRACTOR may provide covered physical health and behavioral health services directly or may enter into written agreements with providers and provider subcontracting entities or organizations that will provide covered physical health and behavioral health services to the members in exchange for payment by the CONTRACTOR for services rendered. The CONTRACTOR shall enter into written agreements with providers to provide covered long-term care services. The CONTRACTOR shall not directly provide long-term care services.
  2.11.1.3   When the CONTRACTOR contracts with providers, the CONTRACTOR shall:
  2.11.1.3.1   Not execute provider agreements with providers who have been excluded from participation in the Medicare, Medicaid, and/or SCHIP programs pursuant to Sections 1128 or 1156 of the Social Security Act or who are otherwise not in good standing with the TennCare program;
  2.11.1.3.2   Consider: the anticipated TennCare enrollment; the expected utilization of services, taking into consideration the characteristics of specific TennCare populations included in this Agreement; the number and types of providers required to furnish TennCare services; the number of contract providers who are not accepting new members; and the geographic location of providers and TennCare members, considering distance, travel time, the means of transportation ordinarily used by TennCare members, and whether the location provides physical access for members with disabilities;
  2.11.1.3.3   Have in place, written policies and procedures for the selection and retention of providers. These policies and procedures shall not discriminate against particular providers that service high risk populations or specialize in conditions that require costly treatment;

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  2.11.1.3.4   Not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification. The CONTRACTOR’s ability to credential providers as well as maintain a separate network and not include any willing provider is not considered discrimination;
  2.11.1.3.5   Give affected providers written notice if it declines to include individual or groups of providers in its network; and
  2.11.1.3.6   Maintain all provider agreements in accordance with the provisions specified in 42 CFR 438.12, 438.2 14 and Section 2.12 of this Agreement.
  2.11.1.4   Section 2.11.1.3 shall not be construed to:
  2.11.1.4.1   Require the CONTRACTOR to contract with providers beyond the number necessary to meet the needs of its members and the access standards of this Agreement; however, the CONTRACTOR shall contract with nursing facilities pursuant to the requirements of Section 2.11.6 of this Agreement and shall contract with at least two (2) providers for each HCBS to cover each county in the Grand Region, as specified in Section 2.11.6.3;
  2.11.1.4.2   Preclude the CONTRACTOR from using different reimbursement amounts for different specialties or for different providers in the same specialty; however, the CONTRACTOR shall reimburse long-term care services in accordance with Sections 2.13.3 and 2.13.4; or
  2.11.1.4.3   Preclude the CONTRACTOR from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to members.
  2.11.1.5   The CONTRACTOR may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member who is his or her patient for the following:
  2.11.1.5.1   The member’s health status, medical, behavioral health, or long-term care, or treatment options, including any alternative treatment that may be self administered;
  2.11.1.5.2   Any information the member needs in order to decide among all relevant treatment options;
  2.11.1.5.3   The risks, benefits, and consequences of treatment or non-treatment; or
  2.11.1.5.4   The member’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions.
  2.11.1.6   Prior to including a provider on the Provider Enrollment File (see Section 2.30.7.1) and/or paying a provider’s claim, the CONTRACTOR shall ensure that the provider has a National Provider Identifier (NPI) Number, where applicable, and has obtained a Medicaid provider number from TENNCARE.

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  2.11.1.7   If a member requests a provider located outside the access standards, and the CONTRACTOR has an appropriate provider within the access requirements who accepts new members, it shall not be considered a violation of the access requirements for the CONTRACTOR to grant the member’s request. However, in such cases the CONTRACTOR shall not be responsible for providing transportation for the member to access care from this selected provider, and the CONTRACTOR shall notify the member in writing as to whether or not the CONTRACTOR will provide transportation for the member to seek care from the requested provider.
  2.11.1.8   If the CONTRACTOR is unable to meet the access standard for a covered service for which the CONTRACTOR is responsible for providing non-emergency transportation to a member, the CONTRACTOR shall provide transportation regardless of whether the member has access to transportation.
  2.11.1.8.1   In the event the CONTRACTOR is unable to meet the access standard for adult day care (see Attachment III), the CONTRACTOR shall provide and pay for the cost of transportation for the member to the adult day care facility until such time the CONTRACTOR has sufficient provider capacity.
  2.11.1.8.2   The CONTRACTOR is not required to provide non-emergency transportation for HCBS, including services provided through a 1915(c) waiver program for persons with mental retardation and HCBS provided through the CHOICES program, except as provided in Section 2.11.1.8.1 above.
  2.11.1.9   If the CONTRACTOR is unable to provide medically necessary covered services to a particular member using contract providers, the CONTRACTOR shall adequately and timely cover these services for that member using non-contract providers, for as long as the CONTRACTOR’s provider network is unable to provide them. At such time that the required services become available within the CONTRACTOR’s network and the member can be safely transferred, the CONTRACTOR may transfer the member to an appropriate contract provider as specified in Section 2.9.4.
  2.11.1.10   The CONTRACTOR shall monitor provider compliance with access requirements specified in Attachment III, including but not limited to appointment and wait times and take corrective action for failure to comply. The CONTRACTOR shall conduct surveys and office visits to monitor compliance with appointment waiting time standards and shall report findings and corrective actions to TENNCARE in accordance with Section 2.30.7.2.
  2.11.1.11   The CONTRACTOR shall use its best efforts to contract with providers to whom the CONTRACTOR routinely refers members.
  2.11.1.12   TENNCARE reserves the right to direct the CONTRACTOR to terminate or modify any provider agreement when TENNCARE determines it to be in the best interest of the State.
  2.11.1.13   To demonstrate sufficient accessibility and availability of covered services, the CONTRACTOR shall comply with all reporting requirements specified in Section 2.30.7.

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2.11.2 Primary Care Providers (PCPs)
  2.11.2.1   With the exception of members dually eligible for Medicare and TennCare, the CONTRACTOR shall ensure that each member has an assigned PCP, as defined in Section 1, who is responsible for coordinating the covered services provided to the member. For CHOICES members, the CONTRACTOR shall develop and implement protocols that address, at a minimum, the roles and responsibilities of the PCP and care coordinator and collaboration between a member’s PCP and care coordinator.
  2.11.2.2   The CONTRACTOR shall ensure that there are PCPs willing and able to provide the level of care and range of services necessary to meet the medical and behavioral health needs of its members, including those with chronic conditions. There shall be a sufficient number of PCPs who accept new TennCare members within the CONTRACTOR’s service area so that the CONTRACTOR meets the access standards provided in Attachment III.
  2.11.2.3   To the extent feasible and appropriate, the CONTRACTOR shall offer each member (other than members who are dually eligible for Medicare and TennCare) the opportunity to select a PCP.
  2.11.2.4   The CONTRACTOR may, at its discretion, allow vulnerable populations (for example, persons with multiple disabilities, acute, or chronic conditions, as determined by the CONTRACTOR) to select their attending specialists as their PCP so long as the specialist is willing to perform all responsibilities of a PCP as defined in Section 1.
  2.11.2.5   If a member who is not dually eligible for Medicare and TennCare fails or refuses to select a PCP from those offered within thirty (30) calendar days of enrollment, the CONTRACTOR shall assign a PCP. The CONTRACTOR may assign a PCP in less than thirty (30) calendar days if the CONTRACTOR provides the enrollee an opportunity to change PCPs upon receipt of notice of PCP assignment.
  2.11.2.6   The CONTRACTOR shall establish policies and procedures to enable members reasonable opportunities to change PCPs. Such policies and procedures may not specify a length of time greater than twelve (12) months between PCP changes under normal circumstances. If the ability to change PCPs is limited, the CONTRACTOR shall include provisions for more frequent PCP changes with good cause. The policies and procedures shall include a definition of good cause as well as the procedures to request a change.
  2.11.2.7   If a member requests assignment to a PCP located outside the distance/time requirements in Attachment III and the CONTRACTOR has PCPs available within the distance/time requirements who accept new members, it shall not be considered a violation of the access requirements for the CONTRACTOR to grant the member’s request. However, in such cases the CONTRACTOR shall have no responsibility for providing transportation for the member to access care from this selected provider, and the CONTRACTOR shall notify the member in writing as to whether or not the CONTRACTOR will provide transportation for the member to seek care from the requested provider. In these cases, the CONTRACTOR shall allow the member to change assignment to a PCP within the distance/time requirements at any time if the member requests such a change.

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2.11.3 Specialty Service Providers
  2.11.3.1   Essential Hospital Services and Centers of Excellence
  2.11.3.1.1   The CONTRACTOR shall demonstrate sufficient access to essential hospital services which means that, at a minimum, in each Grand Region served by the CONTRACTOR, the CONTRACTOR shall demonstrate a contractual arrangement with at least one (1) tertiary care center for each of the following:
  2.11.3.1.1.1   Neonatal services;
 
  2.11.3.1.1.2   Perinatal services;
 
  2.11.3.1.1.3   Pediatric services;
 
  2.11.3.1.1.4   Trauma services; and
 
  2.11.3.1.1.5   Burn services.
  2.11.3.1.2   The CONTRACTOR shall demonstrate sufficient access to comprehensive care for people with HIV/AIDS which means that, at a minimum, in each Grand Region in which the CONTRACTOR operates, the CONTRACTOR shall demonstrate a contractual arrangement with at least two (2) HIV/AIDS Centers of Excellence located within the CONTRACTOR’s approved Grand Region(s). HIV/AIDS centers of Excellence are designated by the DOH.
  2.11.3.1.3   The CONTRACTOR shall demonstrate a contractual arrangement with all Centers of Excellence for Behavioral Health located within the Grand Region(s) served by the CONTRACTOR.
  2.11.3.2   Physician Specialists
  2.11.3.2.1   The CONTRACTOR shall establish and maintain a network of physician specialists that is adequate and reasonable in number, in specialty type, and in geographic distribution to meet the medical and behavioral health needs of its members (adults and children) without excessive travel requirements. This means that, at a minimum:
  2.11.3.2.1.1   The CONTRACTOR has signed provider agreements with providers of the specialty types listed in Attachment IV who accept new TennCare enrollees and are available on at least a referral basis; and
  2.11.3.2.1.2   The CONTRACTOR is in compliance with the access and availability requirements in Attachments III, IV, and V.
  2.11.3.3   TENNCARE Monitoring
  2.11.3.3.1   TENNCARE will monitor CONTRACTOR compliance with specialty network standards on an ongoing basis. TENNCARE will use data from the monthly Provider Enrollment File required in Section 2.30.7.1, to verify compliance with the specialty network requirements. TENNCARE will use these files to confirm the

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      CONTRACTOR has a sufficient number and distribution of physician specialists and in conjunction with MCO enrollment data to calculate member to provider ratios. TENNCARE will also periodically phone providers listed on these reports to confirm that the provider is a contract provider as reported by the CONTRACTOR. TENNCARE shall also monitor appeals data for indications that problems exist with access to specialty providers.
  2.11.3.3.2   TENNCARE will require a corrective action plan from the CONTRACTOR when:
  2.11.3.3.2.1   Twenty-five percent (25%) or more of non-dual members do not have access to one or more of the physician specialties listed in Attachment IV within sixty (60) miles;
  2.11.3.3.2.2   Any non-dual member does not have access to one or more of the physician specialties listed in Attachment IV within ninety (90) miles; or
  2.11.3.3.2.3   The member to provider ratio exceeds that listed in Attachment IV.
  2.11.3.3.3   TENNCARE will review all corrective action plans and determine, based on the actions proposed by the CONTRACTOR, appeals data, and the supply of specialty providers available to non-TennCare members, whether the corrective action plan will be accepted. Corrective action plans shall include, at a minimum, the following:
  2.11.3.3.3.1   The addition of contract providers to the provider network as documented on the provider enrollment file that resolves the specialty network deficiency;
  2.11.3.3.3.2   A list of providers with name, location, and expected date of provider agreement execution with whom the CONTRACTOR is currently negotiating a provider agreement and, if the provider becomes a contract provider would resolve the specialty network deficiency;
  2.11.3.3.3.3   For those deficiencies that are not resolved, a detailed account of attempts to secure an agreement with each provider that would resolve the deficiency. This shall include the provider name(s), address(es), date(s) contacted, and a detailed explanation as to why the CONTRACTOR is unable to secure an agreement, e.g., lack of provider willingness to participate in the TennCare program, provider prefers to limit access to practice, or rate requests are inconsistent with TennCare actuarial assumptions;
  2.11.3.3.3.4   A listing of non-contract providers, including name and location, who are being used to provide the deficient specialty provider services and the rates the CONTRACTOR is currently paying these non-contract providers;
  2.11.3.3.3.5   Affirmation that transportation will be provided for members to obtain services from providers who are willing to provide services to members but do not meet the specialty network standards;
  2.11.3.3.3.6   Documentation of how these arrangements are communicated to the member; and
  2.11.3.3.3.7   Documentation of how these arrangements are communicated to the PCPs.

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2.11.4 Special Conditions for Prenatal Care Providers
  2.11.4.1   The CONTRACTOR shall have a sufficient number of contract providers who accept members in accordance with TennCare access standards in Attachment III so that prenatal or other medically necessary covered services are not delayed or denied to pregnant women at any time, including during their presumptive eligibility period. Additionally, the CONTRACTOR shall make services available from non-contract providers, if necessary, to provide medically necessary covered services to a woman enrolled in the CONTRACTOR’s MCO.
 
  2.11.4.2   Regardless of whether prenatal care is provided by a PCP, physician extender or an obstetrician who is not the member’s PCP, the access standards for PCP services shall apply when determining access to prenatal care except for cases of a first prenatal care appointment for women who are past their first trimester of pregnancy on the day they are determined to be eligible for TennCare. For women who are past their first trimester of pregnancy on the day they are determined to be eligible, a first prenatal care appointment shall occur within fifteen (15) calendar days of the day they are determined to be eligible. Failure to do so shall be considered a material breach of the provider’s provider agreement with the CONTRACTOR (see Sections 2.7.5.2 and 2.11.4).
2.11.5 Special Conditions for Behavioral Health Services
  2.11.5.1   At the direction of the State, the CONTRACTOR shall divert new admissions to other inpatient facilities to ensure that the Regional Mental Health Institutes do not operate above their licensed capacity.
 
  2.11.5.2   The CONTRACTOR shall identify, develop or enhance existing mental health and/or substance abuse inpatient and residential treatment capacity for adults and adolescents with a co-occurring mental health and substance abuse disorder.
 
  2.11.5.3   The CONTRACTOR shall contract with specified crisis service teams for both adults and children as directed by TENNCARE unless the State approves the use of other crisis service providers.
2.11.6 Special Conditions for Long-Term Care Providers
    In addition to the requirements in Section 2.11.1 of this Agreement and the access standards specified in Attachment III of this Agreement, the CONTRACTOR shall meet the following requirements for long-term care providers.
  2.11.6.1   The CONTRACTOR shall contract with all current nursing facilities (as defined in TCA 71-5-1412(b)), that meet all CMS certification requirements, for a minimum of three (3) years following the effective date of CHOICES implementation. Thereafter, the CONTRACTOR shall contract with a sufficient number of nursing facilities in order to have adequate capacity to meet the needs of CHOICES members for nursing facility services.
 
  2.11.6.2   For community-based residential alternatives, the CONTRACTOR shall demonstrate good faith efforts to develop the capacity to have a travel

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      distance of no more than sixty (60) miles between a member’s community-based residential alternative placement and the member’s residence before entering the facility.
  2.11.6.3   At a minimum, the CONTRACTOR shall contract with at least two (2) providers for each HCBS, other than community-based residential alternatives, to cover each county in the Grand Region covered under this Agreement. For HCBS provided in a member’s place of residence, the provider does not need to be located in the county of the member’s residence but must be willing and able to serve residents of that county. For adult day care, the provider does not have to be located in the county of the member’s residence but must meet the access standards for adult day care specified in Attachment III.
 
  2.11.6.4   The CONTRACTOR shall have adequate HCBS provider capacity to meet the needs of each and every CHOICES member in Group 2 and 3 and to provide authorized HCBS within the timeframe prescribed in Sections 2.9.2, 2.9.3, and 2.9.6 of this Agreement. This includes initiating HCBS in the member’s plan of care within the timeframes specified in this Agreement and continuing services in accordance with the member’s plan of care, including the amount, frequency, duration and scope of each service in accordance with the member’s service schedule.
 
  2.11.6.5   Following the first quarter of implementation, TENNCARE will review all relevant reports submitted by the CONTRACTOR, including but not limited to reports that address provider network, service initiation, missed visits, and service utilization. TENNCARE will use the data provided in these reports to establish long-term care provider capacity requirements and develop performance standards, benchmarks and associated liquidated damages for failure to meet the specified performance standards and benchmarks. TENNCARE will notify the CONTRACTOR of the performance standards, benchmarks, and liquidated damages including the timeframe for imposing liquidated damages.
 
  2.11.6.6   The CONTRACTOR shall develop and maintain a network development plan to ensure the adequacy and sufficiency of its provider network. The network development plan shall be submitted to TENNCARE annually, monitored by TENNCARE per the requirements in Section 2.25 of the Agreement, and include the following minimum elements:
 
  2.11.6.6.1   Summary of nursing facility provider network, by county.
 
  2.11.6.6.2   Summary of HCBS provider network, including community-based residential alternatives, by service and county.
 
  2.11.6.6.3   Demonstration of and monitoring activities to ensure that access standards for longterm care services are met, including requirements in Attachment III and in this Section 2.11.6.
 
  2.11.6.6.4   Demonstration of the CONTRACTOR’s ongoing activities to track and trend every time a member does not receive initial or ongoing long-term care services in accordance with the requirements of this Agreement due to inadequate provider capacity, identify systemic issues, and implement remediation and quality improvement (QI) activities. This shall include a summary of provider network

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      capacity issues by service and county, the CONTRACTOR’s remediation and QI activities and the targeted and actual completion dates for those activities.
 
  2.11.6.6.5   HCBS network deficiencies (in addition to those specified in Section 2.11.6.6.4 above) by service and by county and interventions to address the deficiencies.
 
  2.11.6.6.6   Demonstration of the CONTRACTOR’s efforts to develop and enhance existing community-based residential alternatives (including adult care homes) capacity for elders and/or adults with physical disabilities. The CONTRACTOR shall specify related activities, including provider recruitment activities, and provide a status update on capacity building.
 
  2.11.6.6.7   Where there are deficiencies or as otherwise applicable, annual target increase in HCBS providers by service and county.
 
  2.11.6.6.8   Ongoing activities for HCBS provider development and expansion taking into consideration identified provider capacity, network deficiencies, and service delivery issues and future needs relating to growth in membership and long-term needs.
 
  2.11.6.7   The CONTRACTOR shall assist in developing an adequate qualified workforce for covered long-term care services. The CONTRACTOR shall develop and implement strategies to increase the pool of available qualified direct care staff and to improve retention of qualified direct care staff. The strategies may include, for example, establishing partnerships with local colleges and technical training schools; establishing partnerships with professional and trade associations and pursuing untapped labor pools such as elders. The CONTRACTOR shall report annually to TENNCARE on the status of its qualified workforce development strategies (see Section 2.30.7.8).