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, assisted living facility, or at home.
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 eligibility information. There are additional TennCare categories for some children and families with children. Children and pregnant women with high medical bills also are eligible for TennCare in a program 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 one. You may change MCOs once within the initial 45 days of the date of the assignment letter. You also have the opportunity to change MCOs one month each year (July, in East Tennessee). For a list of TennCare MCOs that serve Knox County see Medical Insurance and Financing.
Before choosing a TennCare plan, think about desired doctor, hospital, and pharmacy, as well as other necessary medical services. Check with each MCO to learn which services are provided–for example, eye and dental care, geriatric assessment). Check with all health-care providers to learn which MCO plans they accept. Choose the MCO that offers the greatest number of needed services and the doctor, hospital, and pharmacy you prefer.
TennCare MCOs must provide transportation for plan members who do not have transportation to medical services. Call your MCO to get instructions about arrangements, which must be made in advance, sometimes as many as five days. 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 pharmacy benefits through Medicare Part D. Enrollees should contact the Tennessee Health Connection with questions.
If you or a family member have a problem with medical services under TennCare, report it to the MCO; if in a nursing home, begin with the administrator. If the problem is not resolved, call the Tennessee Health Connection. If you need further assistance, other possible resources are the TennCare Advocacy Program and the TennCare Solutions Unit. 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 if he or she has TennCare, or, if so, which plan, call the Tennessee Health Connection for assistance.
TennCare MCOs are responsible for providing mental health services, including substance abuse treatment, to enrollees. Some of the organizations listed under Medical Insurance & Financing can provide information about TennCare’s coverage of mental health services and can help to advocate or resolve problems.
Cover Tennessee is a health-care initiative that was designed–before the Affordable Care Act went into effect–to fill the gap for uninsured or underinsured people. Of the agency’s original four programs, the following two still exist, but on a limited basis.
- CoverKids provides comprehensive coverage for children 18 and under 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 (“Go Bare” provision), except for newborns up to four months of age. Maternity coverage is available for pregnant women who meet other eligibility criteria.
- CoverRx is a discount program, not insurance, that provides affordable medication for the uninsured. CoverRx provides prescription assistance to Tennessee residents ages 19 to 64 with household incomes below 250 percent of the federal poverty level. 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.