TennCare
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 a managed care system that is one kind of TennCare. The other kind of TennCare is called TennCare Standard.
Note: Another kind of TennCare Medicaid is that which pays for nursing home stays. To prevent confusion between regular TennCare Medicaid and the program that pays for nursing home care, the latter is referred to in this directory as TennCare Medicaid for Long-Term Care.
TennCare Medicaid is for those 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 Medicaid. Even if you are not eligible for SSI now, you may be eligible for TennCare Medicaid if you had SSI in the past. Legal Aid of East TN has information about this eligibility. There are additional TennCare Medicaid categories for some children and families with children. Children and pregnant women with high medical bills are also eligible for TennCare Medicaid. This type of TennCare Medicaid is called “Medicaid Spend Down.”
Tennessee is planning to offer a new Spend Down program starting in 2007 called the Standard Spend Down program. The benefit package for Standard Spend Down and Medicaid Spend Down will be the same. Unlike the Medicaid Spend Down program, however, enrollment in Standard Spend Down will be limited to 105,000 Tennesseans. Details of this program were still developing at press time. Call TennCare for more information.
When you enroll in TennCare Medicaid, you must choose a Managed Care Organization (MCO). For a list of the TennCare MCOs that serve Knox County see "Medical Insurance & Financing."
Before you choose your TennCare Medicaid 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) and which physicians and hospitals each has contracted with. Choose the MCO that offers the greatest number of services that you need and the doctor, hospital, and pharmacy you prefer.
TennCare Medicaid 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 Medicaid 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 at 1-866-311-4287 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. If you need further assistance, call the TennCare Consumer Advocacy Line (page 133). Whenever you write or mail anything to TennCare, keep a copy and get proof of mailing from the post office or send it by registered 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 Partners handles mental health services for enrollees. All TennCare enrollees have been assigned by the Partners program to a Behavioral Health Organization (BHO), which is a managed care organization for mental health services. TennCare enrollees must go through their BHO for any kind of mental health service, including substance abuse treatment. See "Medical Insurance & Financing" for the BHOs that operate in Knox County.
The Mental Health Association of East TN will provide updated information about TennCare Partners and will help to advocate or resolve problems with TennCare Partners.
Cover Tennessee
Cover Tennessee is a health-care initiative that started in early 2007. The initiative includes five programs:
1. CoverKids provides comprehensive coverage for children. CoverKids provides coverage for children ages 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 (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.
2. AccessTN provides comprehensive coverage for adults, and CoverTN provides basic health coverage for 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 six months, called a "Go Bare" provision. The applicant must have exhausted any continuation coverage, including COBRA. AccessTN will limit enrollment to 6,000 individuals. Seventy-five percent of the positions will be reserved for individuals disenrolled from TennCare due to TennCare reform for up to 60 days after AccessTN opens, or until all positions have been filled.
3. The CoverTN program began on January 1, 2007 (not to be confused with Cover Tennessee, which is the name of the overall health-care initiative of which CoverTN is a part). CoverTN provides basic health insurance coverage to workers who live in Tennessee and work more than 20 hours per week. Premiums will be shared by the employers, employees and the state. The employee's spouse can enroll in CoverTN, but the employer will not have to pay any portion of the spouse's premium.
4. 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 income below 250 percent of the federal poverty level; below $50,000 for a family of four. The program is not available to anyone with prescription drug coverage (including Medicare, TennCare or employment-based coverage.) Participants will have copayments based on income guidelines.
5. The Prevention, Healthy Lifestyles, and Personal Responsibility program teaches healthy lifestyles and eating habits to children and has a grant program to reduce Type 2 Diabetes and obesity.
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