Section 1200-13-01-.11 - MEDICAL (LEVEL OF CARE) ELIGIBILITY CRITERIA FOR TENNCARE REIMBURSEMENT OF CARE FOR CHILDREN IN THE KATIE BECKETT PROGRAM(1) Definitions. See Rule 1200-13-01-.02.(2) PreAdmission Evaluations (PAE). (a) A PAE is required in the following circumstances:1. To determine medical (LOC) eligibility for the Katie Beckett program. A child must have an approved PAE for the applicable LOC to be enrolled into the Katie Beckett program or to be on the waiting list for the Katie Beckett program. 2 When a child requires continuation of the same LOC beyond an expiration date assigned by TennCare.3. When a child's condition has improved such that the previously approved LOC criteria may no longer be met.4. To determine medical (LOC) eligibility to transition from Medicaid Diversion Group Part B to Katie Beckett Group Part A, unless the child has an approved, unexpired PAE for institutional (LOC).(b) A PAE is not required in the following circumstances: 1. To transition from Katie Beckett Group Part A to Medicaid Diversion Group Part B unless the child's condition has improved such that a new PAE is needed to ensure the child would meet "at-risk" LOC.2. To transition from the Continued Eligibility Group Part C to Katie Beckett Group Part A.(c) Medical (LOC) eligibility for children in the Katie Beckett program is determined only in accordance with these criteria established specifically for children under age 18.(d) Subject to (f) below, an approved PAE for a child applying for Katie Beckett Group Part A or Medicaid Diversion Group Part B shall be valid for 365 calendar days beginning with the PAE Approval Date, unless an earlier expiration date is established by TennCare.(e) A valid approved PAE that has not been used within 365 calendar days of the PAE Approval Date must be updated before it can be used for purposes of enrollment into Katie Beckett. To update a PAE for Katie Beckett, the physician shall certify that the Applicant's medical condition on the revised PAE Request Date is consistent with that described in the initial certification and/or assessment and that home-based services, including HCBS, are medically necessary and that the child's needs can be met at home. Such update need not occur until such time that there is a slot available for enrollment into Katie Beckett for which the child meets prioritization criteria. An updated PAE shall not be required for purposes of remaining on the waiting list, unless the Applicant's medical condition has significantly changed such that the previously approved PAE does not reasonably reflect the Applicant's current medical condition and functional capabilities or the Applicant's LOC prioritization score.(f) If the Applicant's medical condition has significantly changed such that the previously approved PAE does not reasonably reflect the Applicant's current medical condition and functional capabilities or the Applicant's LOC prioritization score, a new PAE shall be required.(g) A PAE must include a recent history and physical or current medical records that support the Applicant's functional and/or skilled nursing or rehabilitative needs, as reflected in the PAE. A history and physical performed within 365 calendar days of the PAE Request Date may be used if the Applicant's condition has not significantly changed. Medical records (progress notes, office records, discharge summaries, etc.) may be used to supplement a history and physical and provide current medical information if changes have occurred since the history and physical was performed, or may be used in lieu of a history and physical, so long as the records provide medical evidence sufficient to support the functional and/or skilled or rehabilitative needs reflected in the PAE.(h) A PAE must be certified as follows:1. Physician certification shall be required for enrollment into Katie Beckett Group Part A and the Continued Eligibility Group Part C. Certification of the need for NF care may be performed by a nurse practitioner, clinical nurse specialist, or physician assistant, working in collaboration with a physician.2. Physician certification shall not be required for enrollment into Medicaid Diversion Group Part B.3. Certification of the level of care assessment by a Qualified Assessor shall be required for all PAEs.(i) A PAE may be approved by the Division for a fixed period of time with an expiration date based on an assessment by the Division of the Applicant's medical condition and anticipated continuing need for inpatient nursing care. Notice of appeal rights shall be provided when a PAE is approved with an expiration date.(j) Any deficiencies in a submitted PAE application must be cured prior to disposition of the PAE to preserve the PAE submission date for payment purposes.1. Deficiencies cured after the PAE is denied but within thirty (30) days of the original PAE submission date will be processed as a new application, with reconsideration of the earlier denial based on the record as a whole (including both the original denied application and the additional information submitted). If approved, the effective date of PAE approval can be no more than ten (10) days prior to the date of receipt of the information which cured the original deficiencies in the denied PAE. Payment will not be retroactive back to the date the deficient application was received or to the date requested in the deficient application.2. Once a PAE has been denied, the original denied PAE application must be resubmitted along with any additional information which cures the deficiencies of the original application. Failure to include the original denied application may delay the availability of Medicaid reimbursement for NF services.(3) Level of Care Criteria for Katie Beckett Program.(a) Institutional Level of Care. There shall be two Tiers for Institutional LOC (Tier 1 and Tier 2).1. Tier 1 Institutional LOC. There shall be two types of Tier 1 Institutional LOC (Medical and Behavioral).(i) Tier 1 - Medical Institutional LOC. In order to qualify for Tier 1 - Medical Institutional LOC, all of the following must be met:(I) The child has a medical diagnosis from a qualified treating medical professional of a severe, lifelong chronic medical condition with high mortality and morbidity rates resulting in severe functional limitations and complex medical needs;(II) The child's medical needs are chronic, persistent and expected to last at least twelve (12) months from the date of review;(III) The child's medical needs require high health care service needs and utilization (e.g., frequent ED visits and/or hospital admissions, multiple surgeries, multiple subspecialists);(IV) The child's overall health condition presents the constant potential for complications or rapid deterioration. As a result, the child requires continuous (round-the-clock) observation by an awake trained care provider-a professional nurse, parent, or others properly instructed to immediately detect potential life-threatening situations, respond promptly to render appropriate care, and perform emergency procedures to prevent hospitalization or death;(V) The child's medical needs require frequent, direct, skilled medical interventions (whether provided by a licensed nurse or by a parent or other caregiver who has been trained to provide such care), including skilled medical tasks that are performed multiple times during each 8-hour period and the use of medical equipment to sustain life and prevent life-threatening situations. I. The frequency and complexity of the required skilled medical interventions must be so substantial that without these direct, continuous skilled medical interventions, the child is at imminent risk of institutionalization within an in-patient medical hospital.II. The complex skilled medical interventions must include at least one (1) of the following: A. Ventilator care or non-invasive positive pressure ventilation when required for at least 8 hours per day as a life-sustaining measure for chronic respiratory failure;B. Tracheostomy care requiring suctioning multiple times each 8-hour period;C. Oxygen administration for chronic hypoxia requiring at least 8 hours of oxygen use daily, round-the-clock monitoring of O2 saturation levels, and titration of O2 levels administered;D. Parenteral Nutrition (TPN); and/orE. Dialysis: hemodialysis or peritoneal, in home or at clinic.III. Any interventions not specified above, including site care, shall not meet this criterion.IV. The skilled care needs cannot be acute or of a short-term duration.V. Tasks that are performed only when necessary (PRN) and are not required on an ongoing basis do not meet this criterion.(ii) Tier 1 - Behavioral Institutional LOC. In order to qualify for Tier 1 - Behavioral Institutional LOC, all of the following criteria must be met:(I) The child has one of the following:I. Severe or profound deficits in intellectual and/or adaptive behavior functions, which must include significant communication deficits; orII. Autism and a severe or profound communication disorder;(II) The child has severe co-occurring behavioral health support needs that have persisted for at least six (6) months and are expected to last at least twelve (12) months from the date of review and include persistent and dangerous behaviors that place the child or others at imminent and significant risk of serious physical harm. To meet this criterion, a child must demonstrate dangerous behaviors in at least one of the two dangerous behaviors categories: I. Self-injurious behaviors. These behaviors include: A. Self-hitting, cutting, scratching, burning, pinching, or picking. Repeated and intentional hitting one's self; cutting, burning, scratching, pinching, picking or abrading one's skin hard and frequently enough to break skin, or create a visible mark, burn or tissue damage (does not include piercing or tattooing);B. Severe self-biting. Repeated, intentional and severe biting by child of child's own body parts, in attempt to rupture skin (does not include biting nails or cuticles or biting lip without intent to injure);C. Tearing at or out body parts. Repeated, intentional and severe picking or tearing at body parts in a manner and degree that is likely to cause severe injury (includes rectal digging but does not include picking at a scab or scratches until a body part bleeds or hair pulling); D. Inserting harmful objects into body orifices. Repeated and intentional insertion into body orifices of harmful objects that can tear or puncture the skin;E. Head-banging. Repeated, intentional and severe banging one's head against hard surfaces;F. Body slamming or dropping. Making contact between the body and any object with enough force to make a visible mark or forcefully falling to the floor with no visible cause to fall;G. Self-gagging or strangulation. Any instance of using a hand or other object to induce gagging or vomiting, or strangulation involving the production of unconsciousness or near unconsciousness by restriction of the supply of oxygenated blood to the brain; andH. Eating disorders, the effects of which must be life threatening, as determined by physician. In the case of Anorexia/Bulimia, the child must have malnutrition, electrolyte imbalances or body weight/development below 20th percentile due to the eating disorder or in the case of Pica or Prader Willi syndrome, must at least 4 days per week attempt to ingest non-edible substances or gorge self, as applicable, and require continuous (round-the-clock) "within arm's reach" supervision and immediate engagement of a paid or unpaid trained caregiver to prevent serious harm to the child.II. Physically Aggressive Behaviors toward others: A. A persistent pattern of physically aggressive behaviors not explained by the age or lack of maturity of the aggressor that results in serious harm to others, or that would result in serious harm without intervention or restraints. Includes targeting of violent behaviors against a parent, sibling or other that results in serious harm, or that was intended to inflict serious harm even if actual harm did not occur, or if the act was interrupted and not carried out. May include hitting (using a hand or arm with a closed or open fist to make forceful physical contact with another person), hitting with objects (whether held or thrown), kicking (with foot or leg), headbutting (using the head or face to make forceful physical contact with another person), biting, scratching that breaks skin, pinching when hard enough to cause severe pain, forceful pushing, or hair pulling; orB. Sexually Aggressive Behavior. Attempts and/or successes at touching, groping, undressing others, or grabbing others in their private areas or making physical contact of a perceived sexual nature which is unwanted by the other person; sexual molestation or abuse of others.III. The intensity and frequency of the dangerous behaviors is such that without continuous (round-the-clock) supervision and monitoring and direct, daily community-based therapeutic support and intervention, the child will engage in severe selfinjury or physical aggression toward others and is at imminent risk for institutionalization in an inpatient psychiatric hospital or other placement outside the home (e.g., residential treatment, State custody, or incarceration), even if a formal mental health diagnosis (other than I/DD or autism) has not been made.A. Self-Injurious Behaviors and/or Physically Aggressive Behaviors must occur at least four days a week and require all of the following:(A) Continuous (round-the-clock) "eyes on" observation, supervision and immediate engagement of a paid or unpaid trained caregiver to prevent serious harm to the child or others;(B) Environmental or other restraints; and(C) Engagement of behavioral health professionals for treatment and support; orB. Self-Injurious behaviors and/or physically aggressive behaviors must occur at least once a week if the intensity of such behaviors routinely requires engagement of crisis supports, including behavior crisis teams, law enforcement, or emergency medical treatment to prevent or treat serious harm to the child or others.IV. The child is involved with service systems and/or is receiving treatment from such service systems, but such involvement and/or treatment has not been effective in reducing the child's behaviors or the significant risk of serious physical harm to the child or others, or in increasing the family's capacity to effectively manage the child's behaviors. Involvement with service systems must include at least one of the following:A. Crisis Mental Health Services. The child has an established pattern of utilization of crisis-related behavioral health services over the previous six months, which may include repeated mobile crisis calls, emergency department visits, psychiatric hospitalizations, and/or residential or intensive in-home treatment. The use of psychotropic medications (including PRN usage for purposes of chemical restraint in a behavioral crisis) is not considered a crisis-related behavioral health service. Nor is routine psychiatric care or outpatient therapy.B. Child Protective Services. The child has formal ongoing involvement with the child welfare system specifically related to his or her severe behavioral health needs.C. Criminal Justice System. The child has been engaged with the criminal justice system in the past six months specifically related to his or her severe behavioral health needs. Includes Juvenile and Adult Justice Systems, if applicable.2. Tier 2 Institutional LOC. There shall be three (3) standards for Tier 2 Institutional LOC (Medical, Behavioral, and Functional). A child must meet only one of these standards to meet Tier 2 Institutional LOC. (i) Tier 2 Institutional LOC - Standard 1: Medical. To meet Tier 2 Institutional LOC - Standard 1: Medical, a child must meet all of the following criteria: (I) The child has a medical diagnosis from a qualified treating medical professional of a severe chronic medical condition expected to last at least twelve (12) months and which significantly diminishes his/her functional capacity and interferes with the ability to perform age appropriate activities of daily living at home and in the community;(II) The child requires daily skilled nursing interventions and/or intensive therapy services as defined below: I. Daily skilled nursing interventions may include any of the complex skilled medical interventions listed in Tier 1 - Medical Institutional LOC above (ventilator care or NIPPV, tracheostomy care, O2 administration, TPN, and dialysis), including daily ventilator care or NIPPV for less than 8 hours per day, tracheostomy care requiring daily suctioning but not multiple times per each 8 hours, or daily O2 use less than 8 hours daily.II. Daily skilled nursing interventions may also include, but are not limited to, the following: A. Tube feedings: G-tube, J-tube or NG-tubes;B. Respiratory treatments for airway clearance: chest PT, C-PAP, Bi-PAP, vest device or cough assist device, IPPB treatments. This does not include inhalers or nebulizers.C. Ileostomy, colostomy, or appendicostomy (Malone procedure) care; andD. Need for urinary catheterization daily, or presence of vesicostomy or Mitrofanoff appendecovesicostomy.III. PRN orders do not qualify as daily skilled nursing interventions.IV. Site care, diabetes management, and medication administration, including topical or oral medication, eye drops, inhalers, nebulizers, growth hormone injections, insulin injections, or chemotherapy, shall not meet this criterion.V. Intensive therapy services shall include only medically necessary physical, occupational, or speech therapy provided by a licensed professional therapist and shall apply only if the child is involved in six or more sessions per week with professional therapists.(III) The child has at least two (2) substantial functional limitations in activities of daily living. For purposes of this rule, substantial functional limitations shall include only the following:I. Learning: A substantial functional limitation in learning is defined as a 30% (25% if the child is under one year of age) or greater delay or a score of at least 2 (1.5 if the child is under one year of age) standard deviations below the mean based on valid, standardized and norm referenced measures of aggregate intellectual functioning.II. Communication: A substantial functional limitation in communication is defined as a 30% (25% if the child is under one year of age) or greater delay or a standard score of at least 2 (1.5 if the child is under one year of age) standard deviations below the mean on valid, standardized and norm referenced measures of both expressive and receptive communication functioning.III. Self-Care: The child must demonstrate a deficit in at least one of the following five areas of self-care: E. Eating If a child exhibits deficits in multiple of the self-care activities of daily living identified above, this shall still be counted as one substantial functional limitation (in self-care).
IV. Mobility: The inability to run or to move long distances or between environments related to stamina or ease of movement shall not constitute a mobility deficit.(IV) The child requires an extraordinary (continuous or nearly continuous) level of hands on assistance from others throughout their day to complete everyday activities and supervision/intervention that is significantly beyond that which is routinely provided to other children of the same age; and(V) The intensity and frequency of required skilled interventions and assistance with activities of daily living must be so substantial that it would require at least the level of direct, daily intervention that would be provided in a medical institution, i.e., a nursing facility or intermediate care facility for individuals with intellectual disabilities (ICF/IID).(ii) Tier 2 Institutional LOC - Standard 2: Behavioral. To meet Tier 2 Institutional LOC - Standard 2: Behavioral, a child must meet all of the following criteria:(I) The child has severe or profound deficits in intellectual or adaptive behavior functions, which must include significant communication deficits, or has autism and a severe or profound communication disorder;(II) The child has severe co-occurring behavioral health support needs that have persisted for at least six (6) months and are expected to last at least twelve (12) months from the date of review, including self-injurious behaviors or physically aggressive behaviors toward others as defined in Subpart (3)(a)1.(ii) above, including the intensity and frequency of behaviors, except that an extraordinary level of hands on assistance shall be required as defined in (IV) below;(III) The child has at least two (2) substantial functional limitations in activities of daily living;(IV) The child requires an extraordinary (continuous or nearly continuous) level of hands on assistance to complete everyday activities and supervision/intervention from others throughout their day that is significantly beyond that which is routinely provided to other children of the same age; and(V) The intensity and frequency of required behavioral interventions and assistance with activities of daily living must be so substantial that it would require at least the level of direct, daily intervention that would be provided in a medical institution, i.e., a nursing facility or intermediate care facility for individuals with intellectual disabilities (ICF/IID).(iii) Tier 2 Institutional LOC - Standard 3: Functional. To meet Tier 2 Institutional LOC - Standard 3: Functional, a child must meet all of the following criteria:(I) The child has an intellectual or developmental disability as defined in Rule .02 and at least four (4) substantial functional limitations in activities of daily living that are expected to continue for at least 12 months;(II) The child requires an extraordinary (continuous or nearly continuous) level of hands on assistance to complete everyday activities and supervision/intervention from others throughout their day that is significantly beyond that which is routinely provided to other children of the same age; and(III) The intensity and frequency of assistance with activities of daily living must be so substantial that it would require at least the level of direct, daily intervention that would be provided in a medical institution, i.e., a nursing facility or intermediate care facility for individuals with intellectual disabilities (ICF/IID).(b) At-Risk Level of Care. There shall be two (2) standards for At-Risk LOC (I/DD and Medical). A child must meet only one of these standards to meet At-Risk LOC.1. At-Risk Level of Care Standard 1: I/DD. To meet At-Risk LOC - Standard 1: I/DD, a child must meet both of the following criteria: (i) The child has an intellectual or developmental disability as defined in State law and regulation which significantly diminishes his/her functional capacity and interferes with the ability to perform age appropriate activities of daily living at home and in the community.(ii) This child requires daily intermittent (not continuous) assistance from others to complete everyday activities that is significantly beyond that which is routinely provided to children of that age; or2. At-Risk Level of Care Standard 2: Medical. To meet At-Risk LOC - Standard 2: Medical, a child must meet all of the following criteria: (i) The child has a medical diagnosis from a qualified treating medical professional of a severe chronic medical condition expected to last at least twelve (12) months and which significantly diminishes his/her functional capacity and interferes with the ability to perform age appropriate activities of daily living at home and in the community.(ii) The child requires daily skilled nursing interventions and/or intensive therapy services as defined in Tier 2 Institutional LOC Standard 1: Medical above.(iii) The child has at least one (1) substantial functional limitation in activities of daily living requiring daily intermittent (not continuous) assistance from others to complete everyday activities that is significantly beyond that which is routinely provided to children of that age.(4) Katie Beckett LOC Determinations (a) An Applicant for Katie Beckett shall first be reviewed for At-Risk LOC.(b) All At-Risk LOC determinations for Katie Beckett Applicants shall be made by DIDD in accordance with these rules.(c) An Applicant must be approved for At-Risk LOC in order to be reviewed for Institutional LOC.(d) DIDD will refer an Applicant approved for At-Risk LOC to also be reviewed for Institutional LOC if the Applicant meets certain triggers which indicate he or she may also meet Institutional LOC.(e) The parent or legal guardian of a child applying for Katie Beckett may request that the child is reviewed for Institutional LOC, even if such triggers are not met.(f) All initial Institutional LOC determinations for Katie Beckett Applicants shall be made by a neutral third party contracted with TennCare.(g) All denials of Institutional LOC for Katie Beckett Applicants by the neutral third party shall be reviewed by a licensed physician before a denial can be issued.(h) All Institutional LOC determinations are subject to final review and approval by TennCare.(5) PreAdmission Evaluation Denials and Appeal Rights.(a) An Applicant or the legal representative of the Applicant has the right to appeal the denial of a PAE and to request an Administrative Hearing by submitting a written letter of appeal to TennCare, Division of Long-Term Services and Supports, within thirty (30) calendar days of receipt of the notice of denial.(b) If an Applicant or the legal representative of the Applicant appeals the denial of Institutional LOC, the appellant may request and TennCare will arrange as part of the appeal review, a peer-to-peer review with the child's treating physician in order to gather any additional information regarding the child's medical, behavioral, or functional needs. This information shall be reviewed to determine whether the denial should be overturned prior to the case proceeding to hearing.(c) If TennCare denies a PAE, the Applicant will be notified in the following manner:1. A written Notice of denial shall be sent to the Applicant and, where applicable, to the Designated Correspondent. This notice shall advise the Applicant of the right to appeal the denial decision within thirty (30) calendar days and the opportunity to request a peer-to-peer review with the child's treating physician. The notice shall also advise the Applicant of the right to submit within thirty (30) calendar days either the original PAE with additional information for review or a new PAE. The Notice shall be mailed to the Applicant's address as it appears upon the PAE.2. If the PAE is resubmitted with additional information for review or if a new PAE is submitted, and the Bureau continues to deny the PAE, another written notice of denial shall be sent as described in (5)(b)1.(d) The Applicant has the right to be represented at the hearing by anyone of his/her choice. The hearing will be conducted according to the provisions of the Tennessee Uniform Administrative Procedures Act.(e) Reasonable accommodations shall be made for Applicants with disabilities who require assistance with an appeal.(f) Any Notice required pursuant to this section shall be a plain language written Notice.(g) When a PAE is approved for a fixed period of time with an Expiration Date determined by the Bureau, the Applicant shall be provided with a Notice of appeal rights, including the opportunity to submit an appeal within thirty (30) calendar days of receipt of the notice of denial. Nothing in this section shall preclude the right of the Applicant to submit a new PAE establishing medical necessity of care when the Expiration Date has been reached.Tenn. Comp. R. & Regs. 1200-13-01-.11
Original rule filed June 7, 1982; effective July 22, 1982. Repeal and new rule filed February 23, 1987; effective April 9, 1987. Amendment filed March 22, 1989; effective May 16, 1989. Amendment filed June 8, 1990; effective July 23, 1990. Amendment filed March 18, 1994; effective June 1, 1994. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendments filed May 27, 2010; effective August 25, 2010. Repeal filed February 1, 2013; effective July 29, 2013. Emergency rules filed November 20, 2020; effective through May 19, 2021. Amendments filed February 17, 2021; effective 5/18/2021.Authority: T.C.A. §§ 4-5-202, 4-5-208, 71-5-105, 71-5-106, 71-5-109, 71-5-110, 71-5-111, 71-5-112, and 71-5-164 and TennCare II/III Section 1115(a) Medicaid Demonstration Waiver Extension.