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Notice of Change in TennCare II Demonstration Amendment 22

The Commissioner of the Tennessee Department of Finance and Administration is providing official notification, pursuant to 42 CFR § 447.205 and 59 Fed. Reg. 49249, of intent to file an amendment to the TennCare II Demonstration, as well as corresponding amendments to the Medicaid State Plan, if needed.  The amendment will be filed with the Centers for Medicare and Medicaid Services (CMS), a federal agency located in Baltimore, Maryland, with a Regional Office in Atlanta, Georgia. 

The State is required to meet certain advance notice obligations whenever an amendment to the TennCare Demonstration is filed.  This demonstration amendment, which will be known as “Amendment 22,” is being filed with a proposed effective date of July 1, 2014.

Amendment 22 will implement maximum medical copays on certain TennCare Medicaid and TennCare Standard adults.  Groups of persons who are exempt from these copays include all children under age 21 and the groups listed at 42 CFR § 447.56(a)(1)(vii)-(xi).  However, in accordance with 42 CFR § 447.54(c), no persons will be exempt from the $8 copay on non-emergency use of the Emergency Room listed below.

Certain services are exempt from copays.  These services are listed at 42 CFR § 447.56(a)(2)(i)-(v).

The specific copays to be implemented include the following: 

  1. Inpatient stays.  $75 per admission.
  2. Outpatient visits.  $4 per visit except that no co-pay will be associated with visits from a home health aide, home health nurse or private duty nurse and no co-pay will be associated with visits to a community mental health center or outpatient substance abuse treatment facility.
  3. Non-emergency use of the Emergency Room:  $8 per occasion, defined as a single day.

In accordance with 42 CFR § 447.52(e), providers may require an enrollee to pay cost-sharing as a condition of receiving the service if the individual has a family income that exceeds 100 percent of the Federal Poverty Level. 

In accordance with 42 CFR § 447.56(f), copays incurred by all enrollees in a TennCare household may not exceed an aggregate limit of 5 percent of the family’s income, applied on a quarterly basis.    Copays to be included in the aggregate limit will be those identified in this notice plus copays that are already in place.  

Amendment 22 will also include a request to implement a limit on diapers of 200 per month for adults aged 21 and older who receive these items on an outpatient basis and who need them for medical reasons. 

It is the state’s intention to submit this amendment to CMS with the request that it be approved in time for implementation to occur July 1, 2014.  Corresponding State Plan Amendments will be filed, where appropriate.  We estimate that implementation of the amendment and corresponding State Plan changes will result in a decrease in aggregate annual expenditures of $19,529,700 in State and Federal funds in State Fiscal Year 2015. 

Copies of this notice will be available in each county office of the Tennessee Department of Health.  Written comments may be submitted by email to Susie.Baird@tn.gov or may be mailed to Mr. Darin Gordon, Director, Bureau of TennCare, 310 Great Circle Road, Nashville, Tennessee 37243.  Persons wishing to review copies of written comments received may submit their requests to the same email and/or physical address.