STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM
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1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM BCFA-AT (BPP) HAY 22, 1980
2 Revision: HCFA-PH-87-4 WARCH 1987 (BERC) OHB Ro STATE PLMl UNDER TITLE XIX OF ZHB SOCIAL SECURITY ACT Medical Assistmce Program State/Terri tory: TENNESSEE SECT1 OM PACK YlRIBKRS State Plan Submittal Statement...,..,. 1 SECTION 1 - SINGLE STATE AGENCY ORGANIWTIOlf Designation and Authority Organization for Administration Statewide Operation State Medical Care Advisory Committam (- TN ilo; 8/ 11 Supersedes Approval Date JULA Effective Date TH Bo. HCFA ID: 1002P/0010P
3 Revision: HCFA-PM-87-4 MARCH 1987 (BE) OllB Ilo SECTION 2 - comes AM) BLIGIBILITY... a... m 2.1 Application, Determination of Eligibility. PAGE BWBgRS 10 md Furnishing Medicaid Coverage and Conditions of Eligibility Residmce I3 2.4 Blindness a. 2.5 Disability Financial Eligibility Hedicaid Furnished Out of State C N lo Supersedes Approval Date JUL ' Effectlva Date ry no. - *. HCFA ID: 1002P/0010P -..
4 Revision: HCFA-PH-87-4 XARCH 1987 (BRRC) PACE lllribsrs I mount, Duration, and Scope of Servicms Coordination of Medicaid with Medicam Part B Medicaid for Individuals Age 65 or Ovor in Institutions for Mental Diseuan Special Requirements Applicqbla to Medicaid for Medicare Cost Sharing for Ambulatory Prenatal Care for Pregnant Uomrn during Presumptive Eligibility Period... Sterilization Procedures 31. Qualified Hedicare Beneficiarimn b ' ' TN PO ( Supersedes Approval Date affective ~ ~ t e I *. HCFA ID: 1002P/0010P
5 'Revision: HCPA-PM-87-4 WCX 1987 (BERC) l ' i *... SECTIOY 4 - CElERAt PROCRAX ADMIUISTRATIOV Methods of Administration Hearings for Applicants and Recipients (, 4.3 Safeguarding Information on Applicants -dre~ipiwjtf Medicaid Quality Control Medicaid Agency?raud.Detection md Investigation Program Reports Maintenance of Records... : Availability of Agency Program Manuals Reporting Provider Payments to the Internal Revenue Service Free Choice of Providen Relations with Standard-Setting and Survey Agencies Consultation to Medical Pacilitias Required Provider Agreement Utilization Control i Inspections of Care in Skilled Hursing and Intermediate Care Facilities and Institutions for Mental Diseases Relations with State Health and Vocation.]. Rehabilitation Agencies and Title V Grantees Liens and Recoverie Cost Sharing and Similar Charges Payment for Services 57. m Yo C ' Supersed.~ Approval Date? Iffestive i ate m no: HCFA ID: 1002P/0010P
6 Revision: HCFA-PH-90-2 JANUARY 1990 (BPD) SECTION PACE MRIBERS 4.20 Direct Payments to Certain Recipients for Physicians' or Dentists' Services Prohibition Against Reassignment of Provider Claims Third Party Liability Use of Contracts Standards for Payments for Skilled Nursing and Intermediate Care Facility Services Program for Licensing Administrators of Nursing Homes Disclosure of Survey Information and Provider or Contractor Evaluation Appeals Process for Skilled Nursing and Intermediate Care Facilities Conflict of Interest Provisions ~xcluston of Providers and Suspension of Practitioners Convicted and Other Individuals Disclosure of Information by Providers and Fiscal Agents Income and Eligibility Verification System Medicaid Eligibility Cards for Homeless Individuals a 4.34 Systematic Alien Verification for Entitlements b 4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation c TN No Supersedes TN lo SEP Approval Date Effective Date 7-1-g0 HCFA ID: 1002P/0010P
7
8 OlIB Eo Fiscal ~olicies and Accountability Cost Allocation State Financial Participation Eo ( Supersede. Approval Data JUL "' ~ffectiva Data ' TII no. HCPA ID: 1002P/0010P
9 Revieion: HCFA-PM-91-4 ( BPD ) August M.E NO SECTION PAGE NUMBERS SECTION 7 - GENERAL PROVISIONS Plan Amendments Nondiecrimination Maintenance of AFDC Effort State Governor's Review TN No. - Supersedes TN NO Approval Date Effective Date HCFA ID: 7982E
10
11 + Supplement Revision: HCFA-PM-91-4 (BPD) AUGUST 1991 OMB NO.: 0938: Page 1 No. LIST OF ATTACHMENTS utle of Attachment * A Attorney General's Certification +l.l-b 1.2-A 1.2-B 1.2-C 1.2-D 2.1-A *2.2-A *2.6-A *Forms Provided Waivers under the Intergovernmental Cooperation Act Organization and Function of State Agency Organization and Function of Medical Assistance Unit Professional Medical and Supporting Staff Description of Staff Making Eligibility Determination Definition of an HMO that Is Not Federally Qualified Groups Covered and Agencies Responsible for Eligibility Determinations Supplement 1 - Supplement 2 - Supplement 3 - Reasonable Classifications of Individuals under the Age of 21, 20, 19 and 18 Definitions of Blindness and Disability (Territories onlv) Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home Eligibility Conditions and Requirements (States onlv) Supplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries Supplement 2 - Resource Levels - Categorically Needy, Including Groups with Incomes Up to a Percentage of the Federal Poverty Level, Medically Needy, and Other Optional Groups Supplement 3 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under Medicaid 4 - Section 1902(f) Methodologies for Treatment of Income that Differ from those of the SSI Program TN No Supersedes Approval Date Effective Date lllf92 TN No. R7-1 1 HCFA ID: 7982E
12 Revision: HCFA-PM-51-8 (ME) October No. Title of Attachment Supplement 5 - * Supplement 5a- Suppleaent 6 - Supplement 7 - Supplement 8 - Supplement 8a- Supplement 8b- Supplement 9 - Supplement 10- Supplement 11- OMB No. : Page 2 Section 1902(f) Methodologies for Treatment of Resources that Differ from those of the SSI Program Methodologies for Treatment of Resources for Individuals With Incomes Up to a Percentage of the Federal Poverty Level Standards for Optional State Supplementary Payments Income Levels for 1902(f) States - Categorically Needy Who Are Covered under Requirements More Restrictive than SSI Resource Standards for 1902(f) States - Categorically Needy More Liberal Methods of Treating Income Under Section 1902(r)(2) of the Act More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act Transfer of Resources Consideration of Medicaid Qualifying Trusts--Undue Hardship Cost-Effective Methods for COBRA Groups (States and TerritoriesL *2.6-A Eligibility Conditions and Requirements (Territories only) Supplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy, and Qualified Medicare Beneficiaries Supplement 2 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under Medicaid Supplement 3 - Resource Levels for Optional Groups with Incomes Up to a Percentage of the Federal Poverty Level and Medically Needy Supplement 4 - Consideration of Medicaid Qualifying Trusts--Undue Hardship Supplement 5 - More Liberal Methods of Treating Income under Section 1902(r)(2) of the Act + Supplement 6 - More Liberal Methods of Treating Resources under Section 1902(r)(2) of the Act *Forms Provided - TNNo Supersed Approval Date Effective Date 111/92 TN No i HCFA ID: 7982E
13 Revision: HCFA-PM-91- G (BPD) AUGUST 1991 OMB No.: Page 3 & a Tjtle of Attachment '3.1-A Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy Supplement 1 Case Management Services Supplement 2 - Alternative Health Care Plans for Families Covered Under Section 1925 of the Act 3 Amount, Duration, and Scope of Services Provided Medically Needy Groups C Standards and Methods of Assuring High Quality Care a 3.1-D Methods of Providing Transportation '3.1-E 4.1-A 4.14-A 4.14-B 4.16-A 4.17-A '4.18-A C4.18-B '4.18-C D '4.18-E 4.19-A Standards for the Coverage of Organ Transplant Procedures Standards for Institutions Single Utilization Review Methods for Intermediate Care Facilities Multiple Utilization Review Methods for Intermediate Care Facilities Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home Charges Imposed on Categorically Needy Medically Needy - Premium Charges Imposed on Medically Needy and other Optional Groups Premiums Imposed on Low Income Pregnant Women and Infants Premiums Imposed on Qualified Disabled and Working Individuals Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care 'Forms Provided TN No. - Supersedes Approval Date Effective Date TN No. - HCFA ID: 7982E
14 Revirion: RCFA-PM-91-8 October 1991 (BIB) OKB No.: Page 4 - No. Title of Attachment 4.19-B Methods and Stsndardr for Ertablirhlng Paywnt kt08 - Other Types of Care Supplement 1 - Methodm and Standardr for trtablirhing Payment Utes for Title XVIII Doductible/Coinrurance Payment8 for Renerved Bods Methods and Standard8 for E~tabliahinp Payment Rater - Skilled Nursing and Intemedlate Care Facility Servlcmr Timely-Claims Payment - Definition of Claim Conditions for Direct Payment for Phyricianr' and Dentirtr' Servicee Requirementr for Third Party Liability--Identifying Libble Resources Requirement6 for Third Party Liability--Papent of Claims Cort-Effective Methods for Employmr-Bared Group Health Plans Income and Eligibllity Verification Syrtom Procedurer: Requests to Other State Agencies Method for Isruance of Medicaid Eligibility Cards to Homelees Individuals Criteria for the Application of Specified Remedies for Kursing Facilities *4.3S-5 Alternative Remedies to Specified Remedies for Nursing Facilities 7.24 Methods of Administration - Civil Rights (Title VI) *Forms Provided TN NO Supersedes Approval Date Ef fectlve Date 19* TN -- No HCPA ID: 7982E
15 Revision: HCFA-PM-91-4 AUGUST 1991 (BPD) OMB NO STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM Statemerritory: TENNESSEE Citation 42 CFR As a condition for receipt of Federal funds under title XIX of the Social Security Act, the TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION (Single State Agency) submits the following State plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this State plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. TN No Supersedes TN NO f;bv i 1 i493 Approval Date Effective Date 10119/99
..' MEDICAL ASSISTANCE PROGRAM XIX STATE PLAN UNDER ~ITLE OF THE SOCIAL SECURITY ACT HCFA-AT-80-38 (BPP) ...:...,..; ". '.;..
, w. ~ ~ 'c~c." STATE PLAN UNDER ~TLE XX..' ( OF THE SOCAL SECURTY ACT MEDCAL ASSSTANCE PROGRAM...4 ". HCFA-AT-80-38 (BPP) ~1AY 22, 1980 ',: :~. : :. ~: ~:"'Y.~ :... '0'...:...,..; ". '.;.. ....... ~ -
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