Grier Revised Consent Decree

1. Grier Revised Consent Decree • Daniels v. White, 1979 • 1994 – TennCare • 1999 - Grier Revised Consent Decree

2. Key Provisions Grier outlines the appeal rights of Waiver recipients and Compliance requirements • Appeal must be filed within 30 days • Filed by a recipient or on their behalf • Timing and types of appeals

3. Key Provisions • Denial notices sent to the recipient must meet specific content requirements • Denials based on medical necessity must be supported by an individualized determination

4. When Does Grier Apply? An Enrollee experiences an adverse action regarding TennCare benefits or services (medical assistance funded wholly or in part with federal funds under the Medicaid Act) administered by TennCare through their managed care contractors (MCC)

5. An adverse action is… • Denial • Delay • Termination • Suspension • Reduction • Any act, or failure to act that impacts the quality, availability, or timeliness of a Medicaid MR Waiver Service to an eligible recipient

6. Grier does not apply when: • State-funded services are denied • Person is on the waiting list -not enrolled as a Medicaid service recipient • Services are provided without PA • Dispute over rate for service

7. Provider Responsibilities • Educate staff • Ensure that services are provided consistently and timely • Failure to provide the service in full may result in sanctions or recoupment of funds by DMRS

8. Provider Responsibilities: • Grier is not waived because of an inadequate network • The RO must be informed immediately upon any provider-initiated adverse action

9. Provider-Initiated Adverse Actions • The Regional Office must be informed a minimum of 60 days before ceasing to provide services • Services must continue until a new provider is located and approved