Medicaid, a national health-care program for low-income persons, is cooperatively financed by the state and federal governments. Administered by the state, the program provides medical services to eligible individuals. Benefits cover hospital, nursing home, and outpatient services.
In Tennessee, Medicaid is called TennCare. TennCare CHOICES is the program that pays for long-term care in a nursing facility, an assisted living facility, or at home (click here for more information).
TennCare is for Tennesseans who fit into certain categories, including uninsured women under age 65 who need treatment for breast and cervical cancer (must meet eligibility requirements). Anyone receiving SSI is automatically eligible for TennCare. Even if you are not eligible for SSI now, you may be eligible for TennCare if you received both Social Security and SSI in at least one month after April 1977. Legal Aid of East TN has information about this eligibility. There are additional TennCare categories for some children and families with children. Children and pregnant women with high medical bills are also eligible for TennCare. This type of TennCare is called “Medicaid Spend Down.”
When you enroll in TennCare, you may choose a Managed Care Organization (MCO). If you are an SSI beneficiary or if you don’t choose an MCO, you will be assigned to an MCO. You may change MCOs once within the initial 45 days from the date of the letter informing you of your MCO assignment. You also have the opportunity to change MCOs one month each year (July, in East Tennessee). For a list of the TennCare MCOs that serve Knox County click here.
Before you choose your TennCare plan, think about which doctor, hospital, and pharmacy you want, as well as what other medical services you need. Check with each MCO to learn which services are provided under that plan (for example, eye and dental care, geriatric assessment). Check with all of your health-care providers to learn which MCO plans they accept. Choose the MCO that offers the greatest number of services that you need and the doctor, hospital, and pharmacy you prefer.
TennCare MCOs must provide transportation for people signed up with their plan who do not have transportation to medical services. Call your MCO to get instructions about arranging transportation. Arrangements must always be made in advance, sometimes as much as five days ahead. Even in an emergency, call your MCO for instructions about obtaining transportation.
TennCare provides pharmacy benefits to eligible enrollees. However, enrollees who also have Medicare receive their pharmacy benefits through Medicare Part D. Enrollees should contact the Family Assistance Center with questions.
If you or a family member has a problem with medical services under TennCare, begin by reporting the problem to the MCO; if in a nursing home, begin with the administrator. If the problem is not resolved, call the TennCare Information Line (page 135). If you need further assistance, call the TennCare Advocacy Program (page 134). Whenever you write or mail anything to TennCare, keep a copy and get proof of mailing from the post office or send it by certified mail, return receipt requested. You then have proof that the document was mailed and received.
If you are helping a family member and do not know whether he or she is on TennCare, or which plan he or she is enrolled in, call the TennCare Information Line; they can tell you.
TennCare MCOs are responsible for providing mental health services, including substance abuse treatment, to their enrollees. The Mental Health Association of East TN will provide information about TennCare’s coverage of mental health services and will help to advocate or resolve problems.
Cover Tennessee is a health-care initiative that includes four programs:
- CoverKids provides comprehensive coverage for children ages 18 and younger with household income up to 250 percent of federal poverty level. The applicant must have been without health coverage for a period of three months (a “Go Bare” provision), except for newborns up to four months of age. Maternity coverage is available for pregnant women who meet other eligibility criteria.
- AccessTN provides comprehensive coverage for adults, while CoverTN (item 3, below) provides basic health coverage for employed adults. AccessTN provides
coverage for uninsurable Tennessee residents age 19 or older with no access to insurance at the time of application and who have been without health
coverage for three months (a “Go Bare” provision). The applicant must have exhausted any continuation coverage, including COBRA. Participants must pay
Those who are eligible for AccessTN may also qualify for the Pre-Existing Condition Insurance Plan (PCIP), a federally funded high-risk pool. PCIP is administered by the United States Department of Health and Human Services. The program provides coverage to those who prove a pre-existing medical condition with a denial letter from a private insurer and have been uninsured for at least six months. PCIP offers comprehensive coverage with no pre-existing condition exclusion and no annual or lifetime benefit limit. Like AccessTN, PCIP members are responsible for paying monthly premiums, which vary, depending on the individual’s age.
- The CoverTN program (not to be confused with Cover Tennessee, which is the name of the overall health-care initiative of which CoverTN is a part) provides basic health insurance coverage to workers who live in Tennessee and work an average of 20 hours per week, or are between jobs. Premiums will be shared by the employers, employees, and the state. The employee’s spouse can enroll in CoverTN, but the spouse must pay a two-thirds share of the premium.
- CoverRx is a discount program, not insurance, that provides affordable medication for the uninsured. CoverRx provides prescription assistance to Tennessee residents age 19 to 64 with household incomes below 250 percent of the federal poverty level ($57,625 for a family of four as of March 1, 2012). The program is not available to anyone with prescription drug coverage (including Medicare, TennCare or employment-based coverage.) Participants have copayments based on income guidelines.
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