Judge grants state’s TennCare modification requests

U.S. District Court Judge John Nixon said the latest order concerning the so-called Grier consent decree clarifies questions by the state and supersedes the two previous orders he issued last week.

“The Court finds that there is significant change to warrant modification of the consent decree,” Nixon wrote.

Gov. Phil Bredesen is cutting TennCare rolls and reducing benefits because he says the state cannot afford the program in its current form.

Finance Commissioner Dave Goetz said state officials “are encouraged by Judge Nixon’s action today.”

“Our attorneys are continuing to review his ruling and we remain hopeful that we can preserve coverage for the 97,000 medically needy enrollees,” Goetz said.

The judge’s previous orders gave the state some relief by giving it the power to define what treatments are medically necessary, and authorized the state to require prior authorization for prescription drugs and the ability to limit prescriptions to five per month.

In addition to that, Wednesday’s order imposes additional limitations, such as whether or not an enrollee gets a three-day emergency supply of medication is determined by a pharmacist. Before the supply was automatic.

Also, if an enrollee appeals a denial of coverage, “the state may refuse to pay for the service while the appeal is pending,” according to the latest ruling. Currently, the state must pay for services while an enrollee is appealing.

Pharmacy benefits of the medically needy enrollees were scheduled to end on Monday. But state officials said they needed clarification on some sections of Nixon’s previous rulings, and gave those enrollees a 10-day extension of those benefits.

The extension did not affect another roughly 200,000 people who did lose their benefits on Monday and will eventually be removed from the program all together.

Nixon believes he adequately addressed the state’s questions.

“The defendants now have received sufficient direction from this Court to determine whether they can implement their large-scale reforms,” he wrote.

The state said if it got relief, it could save money and keep the sickest enrollees on TennCare.

Legal advocates said the state should now be able to do that.

“It’s in their hands,” said Lenny Croce, an attorney for the Tennessee Justice Center, the main advocate for enrollees.

Bredesen said Monday he hopes to make a decision about retaining the 97,000 medically needy enrollees sometime this week.