TennCare Appeals Multiply Under New Review Process

A month-old, court-mandated process to appeal coverage denials through TennCare, Tennessee's $5.2 billion Medicaid managed care program, has resulted in a sevenfold increase in the number of appeals, the AP/Nashville Tennessean reports. According to Tennessee Deputy Attorney General Linda Ross, the number of pending appeals has increased to an average of 3,500 per month, compared to 500 per month before the federal court mandate, known as the "Grier consent decree," took effect Nov. 1. The new appeals process is the result of a lawsuit filed by TennCare enrollees, who charged that the process of appealing coverage denials under TennCare was "badly flawed." In 1999, the state agreed to the decree, in part, to prevent a possible takeover of the TennCare program by federal courts. The decree specifies "requirements of notice" when coverage is denied, grants TennCare authority to make final appeals decisions within a certain amount of time and requires, in some cases, for denied care to be provided while the appeal is pending. TennCare's nine managed care organizations have said that the decree could cost them "millions of dollars" (AP/Nashville Tennessean, 12/7). Harold Green, executive director of the Tennessee Association of Health Maintenance Organizations, said, "For every appeal lodged, the administrative and medical costs of TennCare increase for the state and for the MCOs."

Call to Open Enrollment
Despite the Grier case, the co-chairs of the General Assembly's TennCare Oversight Committee on Dec. 7 "renewed their call" to reopen TennCare enrollment to uninsured residents who could pay premiums to join. TennCare closed enrollment to healthy, uninsured adults six years ago, but rolls remained open for Medicaid-eligible residents, uninsured children and adults who have pre-existing conditions that make them unable to secure private insurance. State Rep. Doug Jackson (D) and state Sen. Roy Herron (D) said that reopening the rolls to adults who could afford to pay premiums would be a "boon" to TennCare, which receives two-thirds of its funding from federal tax dollars. Herron said, "A number of us have argued for quite some time that taxpayers who cannot afford private health insurance should be allowed to pay premiums that cover the state portion of the cost and draw down the federal dollars that are available to us" (Commins, Chattanooga Times & Free Press, 12/8). Deputy Finance Commissioner John Tighe told lawmakers that TennCare would "conside[r] reopening enrollment once the program is more financially stable." He added that currently TennCare is "struggling" to keep its current MCOs "afloat" and to build provider networks. Tighe said, "It's getting more and more difficult to get providers to sign up in Medicaid and other public-sector programs, particularly the specialist community, because of managed care. ... It's a program that by its very nature does not pay for the actual cost of care" (Wade, Memphis Commercial Appeal, 12/8).