05 BENEFITS

(1) The following benefits are covered by the CoverKids program for children under age 19 as medically necessary, subject to the limitations stated: (a) Ambulance services, air and ground. (b) Care coordination services. (c) Case management services. (d) Chiropractic care. Maintenance visits not covered when no additional progress is apparent or expected to occur. (e) Clinic services and other ambulatory health care services. (f) Dental benefits: 1. Dental services. Limited to a $1,000 annual benefit maximum per enrollee. 2. Orthodontic services. Limited to a $1,250 lifetime benefit maximum per enrollee. Covered only after a 12-month waiting period. (g) Disposable medical supplies. (h) Durable medical equipment and other medically-related or remedial devices: 1. Limited to the most basic equipment that will provide the needed care. 2. Hearing aids are limited to one per ear per calendar year up to age 5, and limited to one per ear every two years thereafter. (i) Emergency care. (j) Home health services. Prior approval required. Limited to 125 visits per enrollee per calendar year. (k) Hospice care. (l) Inpatient hospital services, including rehabilitation hospital services. (m) Inpatient mental health and substance abuse services. (n) Laboratory and radiological services. (o) Outpatient mental health and substance abuse services. (p) Outpatient services. (q) Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. Limited to 52 visits per calendar year per type of therapy. (r) Physician services. (s) Prenatal care and prepregnancy family services and supplies. (t) Prescription drugs. (u) Routine health assessments and immunizations. (v) Skilled Nursing Facility services. Limited to 100 days per calendar year following an approved hospitalization. (w) Surgical services. (x) Vision benefits: 1. Annual vision exam including refractive exam and glaucoma screening. 2. Prescription eyeglass lenses. Limited to one pair per calendar year. $85 maximum benefit per pair. 3. Eyeglass frames. Coverage for replacement frames limited to once every two calendar years. $100 maximum benefit per pair. 4. Prescription contact lenses in lieu of eyeglasses. Limited to one pair per calendar year. $150 maximum benefit per pair. (2) Mothers of eligible unborn children who are over age 19 receive all benefits listed in Paragraph (1), subject to the same limitations and as medically necessary, except chiropractic services, routine dental services, vision services, and hearing aids and cochlear implants are not covered for these enrollees. (3) Infant Diapers, as defined in Rule 1200-13-13-.01, are covered for enrollees under age 2, as described in Rule 1200-13-13-.04. (4) All services covered by CoverKids must be medically necessary. (5) An MCO or DBM may provide non-covered items or services as cost effective alternatives to covered items or services. Such cost effective alternative services may be provided because they are either (1) alternatives to covered CoverKids services that, in the judgment of the MCO or DBM, are cost-effective or (2) preventative in nature and offered to avoid the development of conditions that, in the judgment of the MCO or DBM, would require more costly treatment in the future. Cost effective alternative services are not covered services and are provided only at the discretion of the MCO or DBM, subject to approval by the Division of TennCare. Authority: T.C.A. §§ 4-5-202, 4-5-203, 4-5-204, 4-5-208, 71-3-1104, 71-3-1106, and 71-3-1110; 42 U.S.C. §§ 1397aa, et seq.; and the Tennessee Title XXI Children’s Health Insurance Program State Plan. Administrative History: Original rules filed November 28, 2018; effective February 26, 2018. Rule was originally numbered 1200-13-21-.04 but was renumbered 1200-13-21-.05 with the introduction of new rule 1200-13-21-.04 filed January 11, 2021; effective April 11, 2021. Amendments filed January 11, 2021; effective April 11, 2021. Emergency rules filed August 7, 2024; effective through February 3, 2025. Amendments filed November 4, 2024; effective February 2, 2025.