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.
- healthinsurance.org contributor
- July 28, 2015
No Medicaid expansion in Tennessee
Tennessee has not yet accepted federal funding to expand Medicaid (TennCare) under the ACA. Doing so would make coverage newly-available to roughly 501,000 of the state’s poorest residents. For now, 161,650 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.
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 23 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.
Governor Haslam pursued modified expansion
In March 2013, Tennessee Governor Bill Haslam unveiled his “Tennessee Plan” for Medicaid expansion. His proposal involves using federal Medicaid funding to purchase private coverage for up to 175,000 to 200,000 low-income Tennessee residents. It also calls 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 are ongoing, and this was still the case in December, although Haslam has said that he has “verbal” approval from the federal government for his plan. In early January, 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, but it too was ultimately rejected. That version called for the state to wait until t he 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 also required the state to obtain a letter from HHS stating that Medicaid expansion could be terminated at any time, at the state’s discretion.
Haslam had considered calling lawmakers back for another special session to address Medicaid expansion again, but said in late April 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.
Who is eligible for Tennessee Medicaid?
Because Tennessee has not 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 HealthCare.gov 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 HealthCare.gov 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 HealthCare.gov. 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 HealthCare.gov, and there were significant delays in processing enrollments once they were sent to TennCare.
Tennessee received harsh criticism from CMS regarding delays in processing enrollments, and eventually lawsuits were filed on behalf of people whose applications were lost in limbo. But the state contends that the fault lies with the federal government and the HealthCare.gov system. TennCare has established a process by which people can request a “delay hearing” if they haven’t received an eligibility decision within 45 days.
2014 enrollment numbers
During the first open enrollment period (October 2013 through April 2014) 83,591 people in Tennessee enrolled in Medicaid or CHIP through HealthCare.gov. From the fall of 2013 to July 2014, total Medicaid and CHIP enrollment in Tennessee increased by 8.1 percent. Between January and May 2014, a total of 126,300 people were newly enrolled in TennCare. The increase in enrollment is due to the “woodworker” effect – people who were previously eligible but are just now enrolling due to the publicity and enrollment efforts surrounding the ACA and the exchange.
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.
Because there have been some delays in processing enrollments submitted through HealthCare.gov, TennCare has established a process for applicants to request a “delay hearing” if they’ve been waiting for an eligibility decision for more than 45 days. If you’re in this situation, you can use this form or call 855-259-0701 to request a delay hearing.
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.