TennCare Responds to Criticism, Lawsuit & Looks to the Future

Sep 04, 2014 at 03:33 pm by Staff

Between a much-publicized letter of reprimand from the Centers for Medicare & Medicaid Services in June and a lawsuit filed in July, the Bureau of TennCare has been on the receiving end of criticism from a number of parties across the state and further afield.

Asked to respond to questions about how the state handles applications for enrollment and to comment on the current lawsuit, Bureau of TennCare Spokesperson Sarah Tanksley shared insights into the processes in place in Tennessee. It should be noted that she asserts applicants can receive in-person assistance with the application process at any county Department of Human Services office. Plaintiffs in the pending lawsuit allege such assistance is nonexistent other than to point to a computer or phone.

As for the pending lawsuit, Tanksley offered the following statement:

“TennCare takes very seriously our role in assuring our citizens have access to the healthcare coverage available under the Affordable Care Act, and we have been successful in enrolling near record numbers of applicants since Jan. 1, 2014. Our interim, federally approved approach, pending the launch of a new computer system that is necessary to fully implement the changes mandated by ACA, relies heavily on the federally facilitated marketplace (FFM). This approach has worked well for the vast majority of applicants. 

“As it became apparent that some smaller groups of applicants encountered barriers obtaining coverage through the FFM, Tennessee has worked … and continues to work … tirelessly to develop workarounds to compensate for these flaws in the federal process, including developing a new workaround that has already helped all of the children named in the suit, a workaround that we communicated to plaintiffs’ counsel the day before they filed. 

“We have been engaged with opposing counsel for many months apprising them of the steps we were taking to continually improve the process for our citizens, and we are disappointed that the result of that open dialogue is yet another lawsuit brought by the Tennessee Justice Center.”

Eligible but not Enrolled

Asked about how many Tennesseans might qualify for coverage who aren’t currently on the TennCare rolls, Tanksley said the numbers vary depending on the source. Prior to Jan. 1, the state developed its own estimates along with other groups including the Kaiser Family Foundation and the Robert Wood Johnson Foundation.

“These pre-January 1 estimates for the Eligible but Not Enrolled population ranged from 60,600 to 101,000. We are not aware of any current estimates that are available on how many individuals have not yet applied,” she said.

The Application Process

“Currently, most individuals seeking to apply for TennCare are directed to apply through the federally facilitated marketplace (FFM) either online via healthcare.gov, by phone or by mail,” explained Tanksley. “Applicants can receive in-person assistance at any county DHS office. Each DHS office has at least one trained certified application counselor … with a total of 350 statewide … to assist in the application process either using a computer kiosk available at each DHS office or, if preferred by the applicant, using a telephone made available at each DHS office.”

Additionally, she noted, individuals with disabilities who need assistance and are unable to go to a DHS office can obtain in-home application assistance through a local Area Agency on Aging & Disability (AAAD) office. Tanksley added that while most applications for TennCare are currently made through the FFM, that isn’t true for every application.

“The state does process some applications directly – including presumptive eligibility for pregnant women and coverage for women with breast or cervical cancer, which can be accessed through local health departments in every county.” She added the state also oversees enrollment processing of babies born to women enrolled in TennCare at the time they give birth and applications from individuals applying for long-term services and supports or Medicare Savings Programs. Applications falling in these categories can be filed directly with TennCare’s Call Center, she explained.

On Aug. 18, the state implemented a newborn presumptive eligibility program. The new program allows participating facilities to enroll newborns in TennCare whose mothers are not enrolled in the program at the time of delivery but have self-reported incomes at or below the TennCare income limit. More information is available at tenncaretopics.com/pregnant-women-eligibility.

The Long-Awaited Computer System

“When the new computer system, referred to as TEDS, is up-and-running, applicants will have a choice between applying for TennCare through the FFM, as most do today, or applying through TEDS. Either doorway should be an equally effective pathway to TennCare eligibility,” Tanksley said.

She added TennCare contracted with Northrop Grumman to develop TEDS, but implementation is behind schedule. “We are in the process of bringing in an internationally recognized consulting firm to evaluate our vendor’s progress to date and provide us with an objective third party estimate of the project timeline.”

Status on the Tennessee Plan

“Conversations between the state and CMS are on-going,” Tanksley said of the Tennessee Plan that Gov. Bill Haslam presented to CMS officials as a way the state would consider expanding coverage.

“We are focused on developing a plan for Medicaid expansion in Tennessee that will align consumer incentives in a manner that promotes consumer engagement in healthy behaviors and healthcare utilization decisions and that will align provider incentives in a manner that moves us from a system that pays for volume to a system that pays for value,” Tanksley explained. “We are working to refine our concept based on past discussions with CMS and given recent developments in other states.”

However, she noted, any decision to expand Medicaid must be approved by state legislators. “The challenge is attempting to develop a proposal that would be acceptable to both CMS and the Tennessee General Assembly.”

Looking Ahead

While working through the immediate demands, Tanksley said the Bureau of TennCare is also focused on the future in terms of care delivery and quality. TennCare, in conjunction with the Department of Intellectual & Developmental Disabilities, has released a concept paper regarding the future of the state’s Home and Community Based Services (HCBS) for individuals with intellectual and developmental disabilities. The concept paper, along with summaries of comments and feedback from key stakeholders, are available online at tn.gov/tenncare/long_hcbsindividuals.shtml.

Additionally, Tanksley said TennCare is looking at creating a new system aligning payment with quality for nursing facilities and certain HCBS providers. Information about the Quality Improvement in Long Term Services and Supports (QuILTSS) initiative can be accessed at tn.gov/tenncare/long_quiltss.shtml.

TennCare Fast Facts

In August 2014, there were 1,279,189 enrolled in TennCare. Of that total, 495,252 were adults and 783,937 were children.

An additional 64,681 children have coverage through enrollment in CoverKids.

Another 123,098 Tennesseans (almost entirely adults) are enrolled in Medicare Savings Programs where the Bureau of TennCare assists individuals not otherwise eligible for Medicaid in paying Medicare premiums and cost sharing.

Eligibility Criteria: In order to be eligible for TennCare, an applicant must first meet criteria to determine if they are “categorically” eligible. The TennCare program primarily covers:

pregnant women,


parents and caretaker relatives of dependent children,

the disabled,

individuals needing long-term services,

and supports women needing treatment for breast or cervical cancer.

Once it is determined an individual meets the categorical requirements, that person is then reviewed against income standards that differ for each eligibility category. In some categories, a review against an asset standard also applies.



QuILTSS Initiative

HCBS Concept Paper

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