97,000 can stay on TennCare
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“What we’re trying to do here is simple: We’re fighting for people,” he said.
Before making a decision, Bredesen said he needed to clarify a ruling by U.S. District Court Judge John Nixon that allows the state to modify the so-called Grier consent decree — an agreement the state made with legal advocates for TennCare patients in 1999.
The state had said it needed to modify the decree to save money and keep thousands of the medically needy, or sickest enrollees, on TennCare.
“Two weeks ago, we received a ruling from federal court Judge John Nixon that we have been awaiting,” Bredesen said. “It’s a ruling that we’ve spent the past week and a half examining, in hopes that it gives us the controls necessary to take this important step. And while we didn’t get everything we asked for, we do believe we have enough to move forward.”
In April, the state, a number of TennCare enrollees, their attorneys and a number of health care stakeholders and providers signed an agreement that called for preservation of the medically needy program in exchange for relief from elements of Grier.
Some of those individuals joined the governor Tuesday during his announcement.
“These were tough negotiations, but both of us, that is the governor and the plaintiff-intervenors, have been able to arrive at a beneficial solution which will impact approximately 100,000 Tennesseans,” said attorney George Barrett, who was allowed to intervene on behalf of enrollees to be cut from TennCare.
However, other legal advocates for enrollees have said the state has enough money in TennCare reserves and other means to retain the medically needy without changing the decree.
Those advocates aren’t against the medically needy being kept on the rolls, they just don’t want thousands of other enrollees to lose certain legal protections because of modifications to Grier.
“We are grateful that the state is going to preserve coverage for 97,000,” Gordon Bonnyman of the Tennessee Justice Center, the main advocate for enrollees, said by telephone. “But we continue to be worried about the 200,000 who are being cut off, and it’s not necessary. There are alternatives, and we hope the state will choose those alternatives.”
Bredesen has said he’s cutting about 190,000 TennCare enrollees and reducing benefits because the state cannot afford the $8.7 billion program in its current form.
Earlier Tuesday, TennCare Director J.D. Hickey told lawmakers on the TennCare Oversight Committee that he’s pleased with the relief the state has gotten from Nixon’s ruling.
“What we’ve won is the right, in some of these instances, to go back and operate this program like the 49 other states operate them and how Medicaid is regulated from a federal standpoint,” Hickey said.
Part of the judge’s ruling allows the state to move forward with some benefit limits, Hickey said, and dismiss enrollee appeals that do not raise an issue of fact. Currently, the state cannot deny an enrollee’s appeal of medical coverage.
Bredesen emphasized during his announcement that the state is still seeking clarification from Nixon on a number of aspects of his ruling regarding prior authorization for prescription drugs and the mechanics of the appeals process.
He said these clarifications will be critical in determining whether the state can soften TennCare’s benefit limits for those enrollees facing the most serious health problems.
Tuesday afternoon, Nixon issued an order that essentially said he wants the state to be able to carry out prior authorization, but wants attorneys for enrollees and the state to collaborate on an effective way to make it work.
“The state needs the ability to convince doctors not to prescribe the most unnecessarily expensive drugs, unless there’s a strong medical reason to do so,” said Ted Carey, one of the intervening attorneys. “If you can enforce that principle, then a prior authorization program can work safely and it can save a lot of money for the state, which allows more people to be kept on the program.”