Medicaid Benefits: Online Database

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Benefits by State: Tennessee (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes					A & B - See state-specific FN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	B1 - $5/MH Clinic visit, B2 - $10/MH Clinic visit				A & B - See state-specific FN
Federally Qualified Health Center Services
Yes				Cost based through combination of MCO and State payments	A & B - See state-specific FN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	B1 - $100/admission, B2 - $200/admission		10 days detoxification treatment/lifetime with $30,000 limit/lifetime on inpatient and outpatient drug and alcohol treatment, inpatient rehab hospital services not covered		A & B - See state-specific FN
Outpatient Hospital Services
Yes	B1 - $25/ER visit if not admitted, B2 - $50/ER visit if not admitted		$30,000 limit/lifetime for drug and alcohol treatment across all types of providers		A & B - See state-specific FN
Rehabilitation Services: Mental Health and Substance Abuse
Yes	B1 - $5/MH Clinic visit, B2 - $10/MH Clinic visit		10 days detoxification treatment/lifetime with $30,000 limit/lifetime on inpatient and outpatient drug and alcohol treatment		A & B - See state-specific FN
Rural Health Clinic Services
Yes					A & B - See state-specific FN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes					A & B - See state-specific FN
Chiropractor Services
No
Dental Services
No
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes	B1 - $15/visit, B2 - $25/visit				A & B - See state-specific FN
Nurse Midwife Services
Yes					A & B - See state-specific FN
Nurse Practitioner Services
Yes					A & B - See state-specific FN
Optometrist Services
Yes			Limited to medical eye care, refractive exams not covered		A & B - See state-specific FN
Physician Services
Yes	B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit				A & B - See state-specific FN
Podiatrist Services
Yes	B1 - $5/visit, B2 - $10/visit				A & B - See state-specific FN
Psychologist Services
Yes					A & B - See state-specific FN
Prescription Drugs
Prescription Drugs
Yes	$3/brand Rx		5 Rxs/month including up to 2 brand Rx, specified additional drugs covered outside limit, OTCs not covered except for prenatal vitamins, barbiturates and benzodiazepines not covered		A - See state-specific FN
Physical Therapy and Other Services
Occupational Therapy Services
Yes					A & B - See state-specific FN
Physical Therapy Services
Yes					A & B - See state-specific FN
Services for Speech, Hearing and Language Disorders
Yes					A & B - See state-specific FN
Products and Devices
Dentures
No
Eyeglasses
Yes			Limited to 1 pair of post-cataract surgery lenses or eyeglasses		A & B - See state-specific FN
Hearing Aids
No
Medical Equipment and Supplies
Yes					A & B - See state-specific FN
Prosthetic and Orthotic Devices
Yes					A & B - See state-specific FN
Transportation Services
Ambulance Services
Yes					A & B - See state-specific FN
Non-Emergency Medical Transportation Services
Yes					A & B - See state-specific FN
Other Services
Diagnostic, Screening and Preventive Services
Yes	B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit				A & B - See state-specific FN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes					A & B - See state-specific FN
Targeted Case Management
Yes					A & B - See state-specific FN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Specified services	Services for the following populations: 2, 4 & 8 - See service-specific FN	Dependent upon the services provided	A - See state-specific FN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes			27 hours/week of nursing services or 35 hours/week of combined nursing and home health aide services, levels slightly higher for persons qualifying for nursing facility care		A & B - See state-specific FN
Hospice Care
Yes					A & B - See state-specific FN
Personal Care Services
No
Private Duty Nursing Services
Yes			Limited to services that support use of ventilator equipment or other life-sustaining technology when constant nursing supervision and monitoring are required		A & B - See state-specific FN
Program of All-Inclusive Care for the Elderly
Yes		Yes	See service-specific FN	Capitated payment	A - See state-specific FN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes	B1 - $100/hospital admission, B2 - $200/hospital admission	Admission to nursing facilities	B - Care in nursing facilities not covered	Hospital payment rate established by MCC, nursing facility-specific prospective cost based per diem for level 1 and lower of facility's cost, charge or 65th percentile per diem cost of similar facilities for level 2	A & B - See state-specific FN
Inpatient Psychiatric Services, under age 21
Yes	B1 - $100/admission, B2 - $200/admission				A & B - See state-specific FN
Intermediate Care Facility Services for the Mentally Retarded
Yes			15 hosp leave days/admission if return to facility intended, 60 therapeutic leave days/year with no more than 14 days/occurrencefor home visit or other therapeutic absence	Lower of reasonable cost or charge, reimbursement for hospital leave days only if 85% occupancy requirement met	A - See state-specific FN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		Admission	10 leave days of any type/year but limited to level 1 facilities	Nursing facility-specific prospective cost based per diem for level 1 and lower of facility's cost, charge or 65th percentile per diem cost of similar facilities for level 2, reimbursement for hospital leave days only if 85% occupancy requirement met	A - See state-specific FN
Religious Non-Medical Health Care Institution and Practitioner Services
Yes					A & B - See state-specific FN

Notes: This State has an approved Section 1115 waiver from CMS under which it serves two distinct populations. Tennessee Medicaid, identified on the tables as “A,” provides a comprehensive package of covered services with some limitations for adults and nominal copayment requirements for prescription drugs. TennCare Standard, identified on the tables as “B,” provides a similar package of services for adults not meeting criteria for Medicaid eligibility except this group is not eligible for long-term care services. Cost sharing requirements in TennCare Standard vary according to income level. TennCare Standard enrollees with income at or above the federal poverty level (FPL) have cost sharing obligations; those with income above 100 percent but below 200 percent of the FPL (identified as B1) have lower copayment obligations than enrollees with income at or above 200 percent of the FPL (identified as B2). All TennCare services with the exception of long-term care are provided through managed care contractors (MCCs): managed care organizations, behavioral health organizations, a dental benefits manager (for children) and a pharmacy benefits manager. MCCs have broad discretion relative to the types of providers they use as long as the providers deliver services within their scope of their licensure and have been appropriately credentialed by the MCC. Within contractual parameters, the MCCs establish their own prior authorization policies, reimbursement methodologies and payment rates. Accordingly, only limitations mandated by the State appear on the tables.