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