TENNESSEE, NORTHERN GEORGIA, AND EASTERN ARKANSAS
The State of Tennessee Bureau of Tenncare - Nursing Facility Diversion program
This information is being provided to Tennessee providers as supplemental information to the Cigna-HealthSpring SNP Model of Care.
On July 15, 2008, the PL 110-275 Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was signed into law and amended titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes.
MIPPA requires Special Needs Plans (SNPs) to contract with their state Medicaid agencies to provide benefits, or arrange for benefits to be provided. Cigna-HealthSpring holds a contract with the State of Tennessee Bureau of TennCare to coordinate care and to provide data to the state on these special needs individuals.
This contract covers Cigna-HealthSpring customers qualifying for both Medicare and Medicaid full benefits (dually eligible) and includes the following dual eligible categories; Qualified Medicare Beneficiary Plus (QMB+), Special Low-Income Medicare Beneficiary (SLMB+), and Other Full Benefit Dual Eligible (FBDE). Cigna-HealthSpring offers its special needs plan, TotalCare, in one or more counties in Tennessee.
Cigna-HealthSpring works collaboratively with TennCare plans to facilitate service authorization requests and responses. Cigna-HealthSpring clinicians evaluate customers’ needs to determine the priority level based on clinical judgment. Cigna-HealthSpring requests care coordination from a customers’ assigned TennCare plan. Cigna-HealthSpring utilizes secure methods for communication with TennCare plans.
Cigna-HealthSpring coordinates Medicare and Medicaid services with TennCare plans for our shared members defined as those TennCare beneficiaries also enrolled in “Total Care”, our dual eligible special needs plan (D-SNP). Cigna-HealthSpring coordinates a variety of benefits and services with TennCare plans.
Detail regarding products and services covered under the TennCare program can be found at https://www.tn.gov/tenncare/topic/quick-guide-to-tenncare-services.
A listing of TennCare-covered services, products, and supplies can be found in TennCare Rules & Regulations at:
- 1200-13-01-.05 [TennCare CHOICES]
- 1200-13-13-.04 [TennCare Medicaid]
- 1200-13-14-.04 [TennCare Standard]
- 1200-13-16-.05 [Medical Necessity]
A listing of services, products, and supplies that are specifically excluded from TennCare coverage can be found in TennCare Rules & Regulations at:
- 1200-13-13-.10 [TennCare Medicaid]
- 1200-13-14-.10 [TennCare Standard]
Inpatient Admissions and Discharge Planning:
Cigna-HealthSpring coordinates care with customers’ TennCare plans for any customer who is:
- Admitted into an acute, Long-Term Acute Care, Rehabilitation, Skilled Nursing, or Mental Health inpatient facility
- Discharged from an IP setting when Medicaid Long-Term Services and Supports, Medicaid home health, or private nursing services may be required.
For care coordination processes to begin at the earliest possible date, Cigna-HealthSpring notifies TennCare plans of admissions for those dual eligible beneficiaries that are enrolled with both Cigna-HealthSpring and the TennCare plan (shared beneficiaries). Notifications include planned and unplanned and observation admissions.
Onsite utilization management is conducted by an Acute Care Case Managers (ACCMs), while post-discharge needs assessment and coordination is done by Community-Based Case Managers (CBCMs). When home and/or community based services may be needed, Cigna-HealthSpring coordinates discharge planning, ensuring care in the most appropriate, cost effective, and integrated setting.
Other Types of Coordination:
Cigna-HealthSpring also generates care coordination requests and notification on a daily basis to TennCare plans for shared beneficiaries for needs identified by ACCMs, CBCMs, and Post-Acute Care Case Managers (PACMs). Cigna-HealthSpring requests coordination within the following categories:
- An impending SNF benefit exhaustion two or more weeks in advance of potential exhaustion
- Invitation to participate in an Interdisciplinary Care Team meeting
- Referral for CHOICES program enrollment
- Request for DME and other non-covered benefits/services
- Request for Case Management
- General communication to ensure robust plans of care including any known transitions to a nursing facility
Inbound Coordination Requests:
Cigna-HealthSpring works collaboratively with TennCare plans to facilitate service authorization requests and responses from them. Cigna-HealthSpring responds to inbound coordination requests within the time frame mandated by TennCare according to requesting organization assigned priority level. Cigna-HealthSpring responds to requests designated “High” priority within 24 hours of receiving the request, to “Medium” priority within 5 business days, and to “Low” priority requests within 1 calendar month of receiving the request. Cigna-HealthSpring reviews daily inbound requests to assign each request according to the coordination type and/or comments and/or as needed, for example, according to care coordinator availability and priority level. Cigna-HealthSpring utilizes secure methods for communication with the MCO.
Nursing Facility Diversion Program:
TennCare plans’ nursing facility diversion programs support timely transitions to community and access to medically necessary services.
At a minimum, target groups for nursing facility diversion include:
- Beneficiaries waiting for admission to a nursing facility
- CHOICES beneficiaries living at home or in a Community Based Residential Alternative (CBRA) who have had negative change in circumstances or health and are requesting nursing facility services
- Beneficiaries who have been admitted to an inpatient hospital or rehabilitation center and who are not current nursing facility residents
- Beneficiaries who are admitted for short term stays to nursing facilities, regardless of payer sources
TennCare plans educate and train key staff (case managers, care coordinators, etc.) to identify beneficiaries who may be candidates for diversion. Care managers work with providers to facilitate timely transitions and to carry out follow up activities to ensure sustainable community living.
TennCare’s CHOICES program covers Long Term Services and Supports (LTSS) such as Nursing Facilities, Intermediate Care Facilities, and Home and Community Based Services (HCBS) providers. HCBS provide needed help to assist a person in remaining at home or in the community as an alternative to residential nursing facility care.
There are four groupings within the CHOICES program.
- CHOICES Group 1: Beneficiaries who currently receive nursing home care
- CHOICES Group 2: Beneficiaries who meet nursing home criteria, but desire to remain in their homes
- CHOICES Group 3: Beneficiaries who don’t meet nursing home criteria, but need a more moderate package of home care services to delay or prevent the need for nursing home care
- ECF CHOICES: Employment and Community First (ECF) CHOICES is a managed LTSS program that offers home and community-based services to eligible individuals with intellectual and developmental disabilities in order to promote competitive employment and integrated community living as the first and preferred option. There are three different benefit plans benefit plans/packages within ECF CHOICES to meet the differing needs of the ID/DD population:
- Group 4: Essential Family Supports
- Group 5: Essential Supports for Employment and Independent Living
- Group 6: Comprehensive Supports for Employment and Community Living
TennCare beneficiaries enrolled in the CHOICES program receive the following types of home care services listed below. TennCare plans administer the CHOICES program for their beneficiaries.
Personal care visits, attendant care , home-delivered meals, Personal Emergency Response System, adult day care, in-home respite care, in-patient respite care, assistive technology, minor home modifications, pest control, community-based residential alternatives, assisted care living facility, community living supports , critical adult care home , and companion care.
More information on CHOICES can be found at https://www.tn.gov/tenncare/topic/choices.