Shift puts about 130,000 TennCare enrollees into new category

Gov. Phil Bredesen proposes to more specifically define the terms of eligibility for those in the program and align their benefit levels accordingly. As it’s now structured, most enrollees do not have to make co-payments, and none have benefit limits.

The extent of the new restrictions, if approved by the federal government, will be limited by Medicaid standards. Bredesen proposes moving some people out of the core population, which will be called “TennCare Medicaid,” and creating a new category called “TennCare Standard.”

The TennCare Standard population will not have as many legal protections as those in the basic Medicaid population, and will be required to make co-payments ranging from $1 to as much as $250 for medical care.

TennCare Medicaid enrollees will not be required to pay co-payments and cannot be removed from the program. Their eligibility criteria are set by the federal government, which pays two-thirds of the cost of the $7.8 billion program.

The shift is part of Bredesen’s effort to cut TennCare’s proposed growth by $1 billion a year by 2008.

Differentiating between people who are Medicaid eligible and those who are on the program only because Tennessee has an expanded program also means those people could be more easily removed from the rolls if circumstances dictate.

“We just said as a matter of philosophy we ought to have anyone in the Standard (population) we could, because it gives us a lot more flexibility in the future,” Bredesen told the Chattanooga Times Free Press.

“If we were either turned down by (the federal government ) or the advocates (for TennCare enrollees) were successful in preventing us from doing something major, we’re going to have to take someone off the rolls, and you can take someone in Standard off the rolls.”

Bredesen says he hopes to have the bulk of the reforms in place by Jan. 1.

The reform plan’s critics say the shift would destroy many legal protections granted to enrollees and could be particularly harmful to children. However, as it now stands, Bredesen proposes exempting all children from all benefit limitations and cost-sharing.

“There is not one person in the TennCare program who is safe with these changes,” said Michele Johnson, an attorney with the Tennessee Justice Center, which repeatedly has sued the state on behalf of TennCare’s 1.3 million enrollees. “Every single person is facing very, very drastic cuts to their health care.”

With federal approval, the reform plan will cap services such as monthly prescriptions and doctors visits for about 20 percent of enrollees. Nearly 80 percent of enrollees, including all children, will not have to pay co-payments for care, including prescriptions and doctor’s visits.

TennCare Director J.D. Hickey said the Tennessee proposals are the kind of things the federal government has approved in the past.

“I think what we’ve put forward we believe to be reasonable and rational,” Hickey said. “At the end of the day, this program needs to be viable.”

Bredesen and Hickey unveiled the reform proposal last week in Nashville. State officials will spend the next month receiving public comment and then forward the request for a new Medicaid waiver to the federal government in September.

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Information from: Chattanooga Times Free Press, www.timesfreepress.com