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Tennessee and the ACA’s Medicaid expansion

Expansion pilot program would only cover limited populations

tennessee Medicaid guide

No Medicaid expansion yet, but efforts continue

Tennessee has not yet accepted federal funding to expand Medicaid (TennCare) under the Affordable Care Act (ACA). Doing so would make coverage newly-available to roughly 352,000 of the state’s poorest residents.  For now, 118,000 of those people are in the coverage gap – ineligible for Medicaid and also ineligible for subsidies in the exchange because their incomes are below the poverty level.

The state is now proposing a TennCare expansion pilot program to CMS, but the expansion would apply to limited populations and would require approval from CMS and the state legislature.

Governor Haslam pursued modified expansion

In March 2013, Tennessee Governor Bill Haslam unveiled his “Tennessee Plan” for Medicaid expansion. His proposal involved using federal Medicaid funding to purchase private coverage for up to 175,000 to 200,000 low-income Tennessee residents.  It also called for copays for some enrollees, payment systems for providers that are based on outcomes rather than fee-for-service, and a clause that requires future renewal of Medicaid expansion to be approved by the legislature.

In November 2014, Haslam announced that his negotiations with the federal government were ongoing, and this was still the case in December, although Haslam had said that he has “verbal” approval from the federal government for his plan. In January 2015, Governor Haslam called for a special session of the Tennessee legislature to address his Insure Tennessee plan. The special session began on February 2.

But Senate committees shut it down

Unfortunately, on February 4, the Senate Health and Welfare Committee voted 7-4 against Haslam’s Medicaid expansion proposal, blocking it from going any further in the legislative process during the 2015 session. Although representatives from the Tennessee Hospital Association, the Tennessee Medical Association, and the Tennessee Business Roundtable all provided support for the Medicaid expansion proposal, it was not enough to sway the conservative lawmakers who were concerned about the long-term costs to the state or the difficulty the state would face if it were to try to repeal Medicaid expansion a few years down the road.

For the record, the federal government pays 100 percent of the cost of covering newly-eligible Medicaid enrollees through 2016, and the state’s share will gradually rise to 10 percent by 2020 – but will never exceed 10 percent.

The Insure Tennessee legislation was considered again by another Senate Committee in March 2015, but it too was ultimately rejected. That version called for the state to wait until the Supreme Court ruled on King v. Burwell before proceeding with Medicaid expansion (on June 25, the Court ruled that premium subsidies are legal in every state, thus preventing destabilization in the individual insurance market in Tennessee).  It also called for a six-month waiting period before Medicaid coverage could be reinstated if it were terminated because an enrollee didn’t pay premiums, and it required the state to obtain a letter from HHS stating that Medicaid expansion could be terminated at any time, at the state’s discretion.

A variety of bills, including SJR0103, HB1324, and HB1271, were introduced to expand Medicaid during the 2015 legislative session, but none of them advanced to a full vote.

Haslam had considered calling lawmakers back for another special session to address Medicaid expansion again, but said in April 2015 that he wouldn’t do so until it appeared that legislators had softened to the idea of Medicaid expansion, or were at least beginning to agree on modifications to the current proposal. Tennessee relies heavily on uncompensated care funding from the federal government, and by the fall of 2015, it was clear that the funding was in peril. Expanding Medicaid would eliminate much of the need for ongoing uncompensated care funding.

3-Star Healthy Task Force

In April 2016, Tennessee House Speaker Beth Harwell detailed the creation of a legislative task force to address access to healthcare in the state. Democrats roundly criticized the task force, calling it a joke and noting that there were no Democrats on the task force. Governor Haslam stopped short of saying that the 3-Star Healthy Project’s formation indicated that Insure Tennessee was dead, but acknowledged that Insure Tennessee hasn’t been able to get traction with the legislature, and noted that the plan that would work best would be one that could garner support from Tennessee lawmakers.

The “3-Star Healthy Project” task force began meeting to come up with proposals that could be sent to the federal government, and by September, they had a TennCare expansion proposal ready to send to CMS. While it’s better than nothing, it’s a far cry from Haslam’s Insure Tennessee proposal.

In its initial phase (assuming CMS and the legislature approve the proposal), the pilot program would expand TennCare eligibility only to people with mental health and substance abuse disorders, and to veterans. These groups would be eligible for TennCare with income up to 138 percent of the poverty level.

Who is eligible for Tennessee Medicaid?

Because Tennessee has not yet expanded Medicaid under the ACA, eligibility guidelines are unchanged from 2013, and non-disabled, non-pregnant adults without dependent children are ineligible for Medicaid, regardless of their income. TennCare is available to the following legally-present Tennessee residents, contingent on immigration guidelines:

  • Adults with dependent children, if their household income doesn’t exceed 105 percent of poverty. This is the highest threshold in the country among states that have not expanded Medicaid.
  • Pregnant women and infants under one, with household income up to 195 percent of poverty.
  • Children age 1 – 5 with household income up to 142 percent of poverty, and children 6 – 18 with household income up to 133 percent of poverty.
  • CHIP (Cover Kids) is available to children with household incomes too high for Medicaid, up to 250 percent of poverty.

How do I enroll?

Enrollment in TennCare is year-round; you do not need to wait for an open enrollment period if you’re eligible for Medicaid

  • Tennessee uses the federally-run insurance marketplace, so you can enroll through or use their call center at 1-800-318-2596.
  • You can go to any of the state’s 95 Department of Human Services offices to apply in-person. You can also use the “find local help” link on to find someone in your community who can help you enroll.
  • You can print a paper application and submit it to your local Department of Human Services office (click here for contact information).

The only way to enroll online is through TennCare has had considerable problems with their Medicaid enrollment system; initially they had planned to build a new system that would be functional by October 1, 2013. But that didn’t work out, and the old system didn’t have the functionality to be upgraded properly. As a result, all enrollments had to go through, and in the early days of operation, there were significant delays in processing enrollments once they were sent to TennCare.

Enrollment numbers

As of August 2016, TennCare was covering 1.55 million people in Tennessee. A total of 1,628,196 people had coverage through Tennessee’s Medicaid and CHIP programs as of July 2016. That’s a 31 percent increase since the end of 2013, despite the fact that the state has not expanded Medicaid. This is known as the “woodworker effect,” as people who were already eligible for Medicaid under the existing guidelines “come out of the woodwork” thanks to the outreach and enrollment efforts under the ACA.

During the first open enrollment period (October 2013 through April 2014) 83,591 people in Tennessee enrolled in Medicaid or CHIP through TennCare requested an additional $180 million from the state in late 2013 because of the rapidly increasing enrollment they were seeing soon after open enrollment began on the exchange.

Tennessee Medicaid history

Tennessee was among the last states to implement Medicaid, with their program taking effect in January 1969, three years after Medicaid was enacted by the first states to embrace it.

TennCare was created in 1994 under a federal waiver that allowed for some deviations from the standard Medicaid program.  TennCare was the first Medicaid program to utilize private sector managed care for all of its members.  Initially, TennCare was available at no-cost for Medicaid-eligible residents, and also on a sliding-fee scale (premiums were subsidized) for Tennessee residents who were not able to obtain other private insurance, particularly those who couldn’t get other coverage because of pre-existing conditions.

By 1995, amid soaring enrollment, TennCare stopped accepting applications from non-Medicaid eligible adults unless they were unable to get other coverage because of pre-existing conditions.  And later the “uninsurable” population eligible for TennCare was reduced by implementing income caps for their eligibility.

TennCare’s financial viability continued to be in question, and in 2005 the state removed about 190,000 beneficiaries from the program, implemented benefit reductions, and put caps on the number of prescriptions a TennCare member could get.

Eventually, Tennessee created CoverTN and AccessTN to provide coverage for certain small business groups, the self-employed, and people who were otherwise uninsurable.  Following the reforms and the shift to only insuring the Medicaid-eligible population through TennCare, the program’s budget seemed to be getting back on track by the late 00’s.

When the ACA was created, it was intended that Medicaid expansion would be nationwide, so subsidies in the exchange were not designed to apply to people living below the poverty level, since they were expected to have access to Medicaid.  But in 2012, the Supreme Court ruled that states could opt out of Medicaid expansion, and Tennessee is one of 19 states that have not yet expanded their programs.

If Tennessee continues to reject Medicaid expansion under the ACA, the state will miss out on $22.5 billion from 2013 to 2022. In addition, Tennessee residents will pay $7.8 billion in federal taxes that will be used to fund Medicaid expansion in states that are expanding coverage – while getting no Medicaid expansion funds for their own state.

Tennessee Medicaid

How to apply

You can enroll online at You can also enroll by phone at 1-800-318-2596 ( phone support). Or you can apply in person or by mail at your local County Social Services Office.

Who is eligible

Parents with dependent children are eligible for Medicaid with household incomes up to 105% of poverty. Children are eligible for Medicaid or CHIP with with household incomes up to 250% of poverty, and pregnant women are eligible with incomes up to 195% of poverty.

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