Section 1200-13-01-.08 - PERSONAL NEEDS ALLOWANCE (PNA), PATIENT LIABILITY, THIRD PARTY INSURANCE AND ESTATE RECOVERY FOR PERSONS RECEIVING LTSS(1) Personal Needs Allowance (PNA). The PNA is established for each Enrollee receiving LTSS in accordance with the Tennessee Medicaid State Plan, approved Section 1915(c) Waiver applications, and these rules. It is deducted from the Enrollee's monthly income in calculating Patient Liability for LTSS. (a) The PNA for each person receiving TennCare-reimbursed services in a NF or an ICF/IID is $50. Persons with no income have no PNA. Persons with incomes that are less than $50 per month (including institutionalized persons receiving SSI payments) may keep the entire amount of their income as their PNA.(b) The maximum PNA for persons participating in CHOICES Group 2, CHOICES Group 3, or ECF CHOICES is 300% of the SSI FBR.(c) The maximum PNA for persons participating in one of the State's Section 1915(c) HCBS Waivers is as follows:1. The Statewide ID Waiver: 200% of the SSI FBR.2. The Arlington ID Waiver: 200% of the SSI FBR.3. The Self-Determination ID Waiver: 300% of the SSI FBR.(2) Patient Liability. (a) Enrollees receiving LTSS are required to contribute to the cost of their LTSS if their incomes are at certain levels. They are subject to the post-eligibility treatment of income rules set forth in Section 1924 of the Social Security Act (42 U.S.C.A. § 1396r-5), and 42 C.F.R. § 435.725.(b) For Enrollees being served in HCBS Waivers, the State must also use institutional eligibility and post-eligibility rules for determining Patient Liability.(c) For Members of the CHOICES 217-Like Group, the CHOICES At-Risk Demonstration Group, the ECF CHOICES 217-Like Group, the Interim ECF CHOICES At-Risk Group, and upon implementation of Phase 2 of ECF CHOICES, the ECF CHOICES At-Risk and ECF CHOICES Working Disabled Demonstration Groups, the State uses institutional eligibility and post-eligibility rules for determining Patient Liability in the same manner as specified under 42 C.F.R. §§ 435.217, 435.236, and 435.726 and Section 1924 of the Social Security Act (42 U.S.C.A. § 1396r-5), if the HCBS were provided under a Section 1915(c) Waiver.(d) For a Member of CHOICES Group 2, CHOICES Group 3, or ECF CHOICES receiving the Short-Term NF Care benefit (for up to 90 days) or an Enrollee in one of the State's Section 1915(c) Waiver programs who is temporarily placed in a medical institution, i.e., a hospital, NF or ICF/IID (for up to 90 days), the post-eligibility calculation shall be performed as if the individual is continuing to receive HCBS. The purpose is to ensure that the individual can maintain a community residence for transition back to the community. After 90 days, or as soon as it appears that the inpatient stay will not be a short-term stay, whichever comes first, a CHOICES Group 2, CHOICES Group 3, or ECF CHOICES Member will be transitioned to CHOICES Group 1 (see 1200-13-01-.31(6)(b) for requirements pertaining to ECF CHOICES Members), or a Waiver participant must be disenrolled from the Waiver, and the institutional post-eligibility calculation shall apply.(e) Patient Liability shall be collected as follows: 1. If the Enrollee resides in a NF, ICF/IID, or receives CBRA services other than Companion Care (i.e., ACLF, Critical Adult Care Home, Community Living Supports, or Community Living Supports - Family Model), the Enrollee must pay his Patient Liability to the residential facility or provider. The residential facility or provider shall reduce the amount billed to the Bureau or the MCO, as applicable, by the amount of the Enrollee's Patient Liability obligation, regardless of whether such amount is actually collected by the facility.2. If a CHOICES Group 2, CHOICES Group 3, or ECF CHOICES Member does not receive CBRA services other than Companion Care, i.e., the Member is receiving HCBS in his own home, the Member must pay his Patient Liability to the MCO. The amount of Patient Liability collected will be used to offset the cost of CHOICES Group 2, CHOICES Group 3, or ECF CHOICES benefits or CEA services provided as an alternative to covered CHOICES Group 2, CHOICES Group 3, or ECF CHOICES benefits that were reimbursed by the MCO for that month. The amount of Patient Liability collected by the MCO cannot exceed the cost of CHOICES Group 2, CHOICES Group 3 or ECF CHOICES benefits (or CEA services provided as an alternative to CHOICES Group 2, CHOICES Group 3 or ECF CHOICES benefits) reimbursed by the MCO for that month.(f) A CHOICES or ECF CHOICES provider, including an MCO, may decline to continue to provide LTSS to a CHOICES or ECF CHOICES Member who fails to pay his Patient Liability. If other Contract Providers or the other TennCare MCO(s) operating in the Grand Division are unwilling to provide LTSS to a CHOICES or ECF CHOICES Member who has failed to pay his Patient Liability, the Member may be disenrolled from the CHOICES or ECF CHOICES program in accordance with the procedures set out in this Chapter.(3) TPL for LTSS. (a) LTC insurance policies are considered TPL and the Bureau is subrogated to all rights of recovery.(b) Applicants for the CHOICES or ECF CHOICES programs who have LTC insurance policies must report these policies to TennCare upon enrollment in the CHOICES or ECF CHOICES program. Applicants may be subject to criminal prosecution for knowingly providing incorrect information.(c) Obligations of CHOICES or ECF CHOICES Members receiving NF or CBRA services (other than Companion Care) having insurance that will pay for care in a NF or other residential facility (including cash benefits to the Member for the cost of such services): 1. If the benefits are assignable, the Member must assign them to the NF or residential facility or provider. These benefits will be used to reduce the amounts that the MCO would otherwise be required to pay the NF or the residential facility or provider for LTSS.2. If the benefits are not assignable, the Member must provide payment to the NF or the residential facility or provider immediately upon receipt of the benefits. These benefits will be used to reduce the amounts that the MCO would otherwise be required to pay the NF or the residential facility or provider for LTSS.(d) Obligations of CHOICES or ECF CHOICES Members receiving non-residential CHOICES HCBS or Companion Care services, or non-residential ECF CHOICES services having insurance that will pay for CHOICES HCBS or ECF CHOICES HCBS (including cash benefits to the Member for the cost of such services):1. If the benefits are assignable, the Member must assign them to the MCO. These benefits will be used to reduce the amounts that the MCO would otherwise be required to pay for CHOICES HCBS or ECF CHOICES HCBS for the Member.2. If the benefits are not assignable, the Member must make payment to the MCO immediately upon receipt of the benefits. These benefits will be used to reduce the amounts that the MCO would otherwise be required to pay for CHOICES HCBS or ECF CHOICES HCBS for the Member.(e) TPL payments do not reduce the amount of Patient Liability an Enrollee is obligated to contribute toward the cost of LTSS, except in instances where the total cost of LTSS for the month is less than the combined total of TPL payments and the member's Patient Liability amount, in which case, TPL shall be collected first. The NF shall then collect Patient Liability up to the total cost of LTSS provided for the month.(f) If benefits received by the policyholder are not paid to the facility or MCO, as applicable, such benefits shall be considered income, and may render the person ineligible for TennCare (including LTSS) benefits.(4) Estate Recovery. Persons enrolled in TennCare LTSS programs are subject to the requirements of the FERP as set forth under Section 1917(b) of the Social Security Act, 42 U.S.C.A. § 1396p(b). (a) The State is required to seek adjustment or recovery for certain types of medical assistance from the estates of individuals as follows: 1. For persons age fifty-five (55) and older, the State is obligated to seek adjustment or recovery for NF (including ICF/IID) services, HCBS, and related hospital and prescription drug services.2. For permanently institutionalized persons under age fifty-five (55), the State is obligated to seek adjustment or recovery for the institutional services.(b) Estate recovery shall apply to the estates of individuals under age fifty-five (55) who are inpatients in a NF, ICF/IID, or other medical institution and who cannot reasonably be expected to be discharged home.(c) A determination that an individual cannot reasonably be expected to be discharged to return home shall be made in accordance with the following. 1. The PAE for LOC that is certified by the physician shall specify whether discharge is expected and the anticipated length of stay in the institution.2. The following shall be deemed sufficient evidence that a person cannot reasonably be expected to be discharged to return home and is thus permanently institutionalized: (i) An approved PAE certified by the physician indicating that discharge is not expected; or,(ii) The continued stay of a resident of a medical institution at the end of a temporary stay predicted by his physician at the time of admission to be no longer than six (6) months in duration.(d) Written notice of the determination that the individual residing in a medical institution cannot reasonably be expected to be discharged to return home shall be issued to the individual or his Designated Correspondent. The notice shall explain the right to request a reconsideration review. Such request must be submitted in writing to the Bureau, Long-Term Services and Supports, within thirty (30) days of receipt of the written notice. The reconsideration review shall be conducted as a Commissioner's Administrative Hearing in the manner set out in Rule 1200-13-01-.10(7).Tenn. Comp. R. & Regs. 1200-13-01-.08
Original rule filed May 15, 1980; effective June 29, 1980. Amendment filed May 27, 1983; effective June 27, 1983. Amendment filed February 22, 1991; effective April 9, 1991. Emergency rule filed March 1, 2009; effective through August 28, 2010. Amendment filed May 27, 2010; effective August 25, 2010. Emergency rules filed June 29, 2012; effective through December 26, 2012. Repeal and new rule filed September 26, 2012; effective December 25, 2012. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 30, 2016; effective 12/29/2016.Authority: T.C.A. §§ 4-5-202, 71-5-105, and 71-5-109.