Tennessee

In Tennessee:
As of 2013, 804,840 individuals were eligible for EPSDT through Tennessee’s Medicaid program. According to CMS data from 2013, Tennessee achieved an EPSDT screening ratio of 81% and a participation ratio of 59%. 368,408 children received dental services of any kind, with 339,568 receiving preventive dental services.
Last updated May 2014
Medical Necessity
Tennessee Code 71-5-144 defines Medical Necessity as follows:
“To be determined to be medically necessary, a medical item or service must be recommended by a physician who is treating the enrollee or other licensed healthcare provider practicing within the scope of the physician’s license who is treating the enrollee and must satisfy each of the following criteria:
  1. It must be required in order to diagnose or treat an enrollee’s medical condition. The convenience of an enrollee, the enrollee’s family, or a provider, shall not be a factor or justification in determining that a medical item or service is medically necessary;
  2. It must be safe and effective. To qualify as safe and effective, the type and level of medical item or service must be consistent with the symptoms or diagnosis and treatment of the particular medical condition, and the reasonably anticipated medical benefits of the item or service must outweigh the reasonably anticipated medical risks based on the enrollee’s condition and scientifically supported evidence;
  3. It must be the least costly alternative course of diagnosis or treatment that is adequate for the medical condition of the enrollee. When applied to medical items or services delivered in an inpatient setting, it further means that the medical item or service cannot be safely provided for the same or lesser cost to the person in an outpatient setting. Where there are less costly alternative courses of diagnosis or treatment, including less costly alternative settings, that are adequate for the medical condition of the enrollee, more costly alternative courses of diagnosis or treatment are not medically necessary. An alternative course of diagnosis or treatment may include observation, lifestyle or behavioral changes or, where appropriate, no treatment at all; and
  4. It must not be experimental or investigational. A medical item or service is experimental or investigational if there is inadequate empirically-based objective clinical scientific evidence of its safety and effectiveness for the particular use in question. This standard is not satisfied by a provider’s subjective clinical judgment on the safety and effectiveness of a medical item or service or by a reasonable medical or clinical hypothesis based on an extrapolation from use in another setting or from use in diagnosing or treating another condition”
Managed care contracts require that if a managed care organization’s EPSDT “screening rate is below ninety percent (90%), as determined in the most recent CMS 416 report, the CONTRACTOR shall conduct New Member Calls for all new members under the age of twenty- one (21) to inform them of TENNderCare services including assistance with appointment scheduling and transportation to appointments.”
Tennessee is one of only 12 states that require MCOs to be accredited by the National Committee for Quality Assurance (NCQA). This includes the reporting of Health Care Effectiveness Data and Information Set (HEDIS) data, from which several measures in the CHIPRA core set of measures for children are drawn, including adolescent well-care visits and well child visits in the first 15 months of life.
Managed care organizations must secure services for enrollees from a range of behavioral health providers, including: community mental health agencies; case management agencies; psychiatric rehabilitation agencies; psychiatric and substance abuse residential treatment facilities; and psychiatric and substance abuse inpatient facilities.
Tennessee also has three different Home and Community Based Services Waiver programs that it uses to provide behavioral health services: the Arlington Waiver Program, Self Determination Waiver Program, and Statewide Waiver Program. The Self Determination and Statewide waiver programs include children with developmental delays and intellectual disabilities as part of the target population. The Statewide Waiver Program in particular is explicitly aimed at children. Services provided by Tennessee through these waivers include, but are not limited to:
  • Behavioral Respite Services
  • Behavior Services
  • Day Services
  • Occupational Therapy
  • Residential Habilitation
  • Support Coordination
  • Transitional Case Management
Support to Providers
Tennessee maintains a TENNderCare provider page that contains information on a number of topics including: provider requirements, screening information, periodicity schedule, screening guidelines, and screening tools. Tennessee also staffs a number of regional and statewide EPSDT Coordinators to assist managed care contractors. Additionally, anyone that works directly with the EPSDT population is required to take the TENNderCare training program offered by the Bureau of TennCare. The training includes a slide show outlining the TENNderCare program, as well as a training video, which covers specific elements of the federal guidelines for EPSDT.

Support to Families
Tennessee’s TENNder Tots and TENNderCare For Teens page includes information for families both on the benefits available to the families, as well as resources on a number of different health areas. The state has also developed a, “Welcome to TENNderCare,” overview for families, which outlines screening/check-up schedules and the different services (including behavioral health and dental) that children receive through the program.
Tennessee has an initiative called TENNderCare Connection, which seeks to ensure coordination of care between the managed care organizations (MCOs) and school-based medically necessary services. This initiative was created through an interagency agreement between the Tennessee Department of Education and the Bureau of TennCare. To assist in this process, Tennessee has developed a form that delineates the responsibilities of TennCare, the MCOs, and the Schools to coordinate care.
Managed care contracts also require that MCOs “shall have written policies and procedures for the TENNderCare program that include coordinating services with child-serving agencies and providers.”
Tennessee provides dental services to children through its TENNderCare (EPSDT) program. The state contracts with DentaQuest to serve as the Dental Benefits Manager Prepaid Ambulatory Health Plan. Services provided to TENNderCare beneficiaries include: six-month appointments, screens and diagnostic tests, topical fluoride treatment, pit and fissure sealants, and substance abuse counseling. Tennessee does not provide orthodontic treatment (braces) unless the child is diagnosed with severe handicapping malocclusion.