TennCare is Tennessee’s Medicaid program.152 Adults who have no insurance must fit into one of the TennCare eligibility categories. Those eligible for Families First or SSI benefits automatically receive TennCare coverage. Other eligibility categories include some children and pregnant women who are low-income or have medical bills, some families with minor children, some women with breast or cervical cancer, some people who have received SSI in the past and now receive Social Security benefits, and some people in nursing homes or under long-term care.
Managed Care Organizations under TennCare
Persons covered by TennCare sign up for a Managed Care Organization (“MCO”). Once in a given MCO, an enrollee can only be treated by doctors or hospitals that have signed up with that group. When enrollees sign up for TennCare, they should find out to which MCOs their medical providers belong. If an enrollee is having trouble getting treatment approved or paid by an MCO, he or she can file a grievance with the MCO, and the MCO must respond within 30 days. A grievance can be further appealed to TennCare and then to the Department of Health. Problems with eligibility and premiums can be appealed directly to TennCare.
Prescription Drugs under TennCare
Prescription drug coverage is limited under TennCare. Depending on the medications, only a certain number of prescriptions per month will be paid by TennCare. Only the drugs on TennCare’s list are automatically approved for TennCare coverage. Other drugs can be approved if they are medically necessary, but the doctor has to obtain approval from TennCare. However, if a doctor prescribes a drug not on the list, a pharmacist must give a three-day supply of the medicine to allow time to request approval. The MCO should pay for the three-day supply even if the drug is not on the list. Some drugs do not count against the monthly limit. People should work with their pharmacists so that the most expensive medications are covered.
TennCare also offers long-term services and support through nursing facilities and home and community-based services. TennCare “CHOICES,” which was implemented in 2010, is a program providing long-term care to elderly persons and persons with disabilities. CHOICES aids elderly persons and persons with disabilities in everyday activities through in-home care and nursing homes. To qualify for CHOICES, the applicant must need the level of care provided in a nursing home or meet the “at risk” criteria for nursing home level of care and qualify financially for Medicaid long-term care.
Applying for TennCare
Most applications for TennCare must be filed through the Health Insurance Marketplace. Applications are available online at www.healthcare.gov. Each local DHS office sets aside a computer and usually has someone available to help applicants who do not have Internet access. If you are denied TennCare or have questions about TennCare appeals, you can contact the Tennessee Justice Center at 877-608-1009.
Affordable Care Act
Some people who are not eligible for TennCare may be eligible for subsidies or tax credits to help pay for insurance under the Affordable Care Act. To apply, go online at www.healthcare.gov or call 1-800-318-2596. To get help to apply, call 1-844-644-5443 to schedule an appointment with an independent certified navigator.
Places to Go for Possible Free or Low-Cost Medical Assistance
Knox County Health Department
140 Dameron Avenue
Knoxville, TN 37917
Interfaith Health Clinic
315 Gill Avenue
Knoxville, TN 37917
Cherokee Health System
2018 Western Avenue
Knoxville, TN 37921
Peninsula Mental Health Center
1451 Dowell Springs Boulevard
Knoxville, TN 37909
Helen Ross McNabb Mental Health
201 W. Springdale Avenue
Knoxville, TN 37917
152 See State of Tennessee TennCare, What’s New with TennCare, available at http://www.tn.gov/tenncare.