TennCare enrollees may not get benefits info with new plan

The plan, which officials say could save the state $2.5 billion in the next four years, includes limits on services and prescriptions, as well as co-payments for some enrollees.

Bredesen hopes to begin implementing the reform plan on Jan. 1.

“You have 1.3 million people (on TennCare), and keeping track of that and notifying them on time is a huge cost,” the governor said during a phone interview this week.

The reform plan was presented by Bredesen and TennCare Director J.D. Hickey last week and will be sent next month to Washington, D.C., for approval from the U.S. Centers for Medicare and Medicaid Services. Federal officials do not have a deadline to rule on Tennessee’s application.

TennCare officials are now seeking public comment on the proposal.

The federal government pays two-thirds of the cost of the $7.8 billion TennCare program, which provides health care for 1.3 million poor, disabled and otherwise uninsured enrollees.

About 20 percent of those enrolled in TennCare could face benefit limits for prescriptions, doctor’s visits, X-rays and hospital care. TennCare would not pay for treatment exceeding the limits, leaving that for the patients.

Among the proposed caps on services are limits of six prescriptions a month, 10 doctor’s visits a year and 45 days of inpatient hospital care.

The other 80 percent of enrollees will not have their benefits limited because they fall into protected categories that include children, pregnant women and the disabled.

Enrollees could have trouble tracking their health care benefits under the new plan, said Michele Johnson, an attorney with the Tennessee Justice Center. The center repeatedly has sued the state on behalf of TennCare enrollees.

“It just seems like basic fairness that you’d say to someone, ‘We’re not giving you any more health care,'” Johnson said.

Notifying enrollees when they approach or exceed their limits would be too difficult and open the state to legal challenges, Bredesen said.

“In general, you have people who are mobile, and we have terrible problems keeping up with the addresses of people,” he said. “I want to leave it as an option in the future, but let’s not get ourselves in trouble in the future, because we failed to do something that is very hard to do.”

Hickey said the state might consider creating an information line for providers to learn how much covered treatment remains for their patients. According to the proposal, doctors, pharmacists and other providers can deny nonemergency treatment to TennCare enrollees who can’t pay for their care.

“As we look out and we think about long-term what are potential solutions here, we’d love to make that information available,” Hickey said. “That point is several years out.”

Russ Miller, a spokesman for the Tennessee Medical Association, said physicians won’t know if the care they provide a TennCare enrollee will be paid until after they treat a patient and submit a claim.

“It’s already on our radar,” he said. “If I’m number 11, how am I supposed to know? That’s a question we have.”

The state also may consider finding a way for enrollees to check on how much care they’ve used, said TennCare spokeswoman Marilyn Elam. But that option is not guaranteed, she said.

“We’re still deciding how we’re going to implement some of these things,” Elam said. “We’re looking for public input. That’s what this month is for.”

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On the Net:
TennCare Bureau: http://www.state.tn.us/tenncare
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Information from: Chattanooga Times Free Press, www.timesfreepress.com