Tuesday, February 24, 2015
Healthcare programs within USA
Tenncare was implemented in 1994 and at first covered three programs: Group 1(Medical Eligibles), Group 2(Uninsured people who lacked access to insurance of a prior date-March 1993- and still continued to lack access) and Group 3(Uninsurable people who were turned down for health insurance due to certain medical conditions).In December 1994 Tenncare almost reached its capacity for the uninsured category and couldn’t accept anyone else, but if you were on Medicaid at the time and were about to lose and fit the uninsured category, you were allowed to continue the program. This was when TennCare possibly realized that they need to be more specific about benefits to make sure the ideal capacity is reached. Tenncare expanded to have services for substance abuse and mental health in 1996. An agreed order known as Grier had helped people in appealing denials they had gotten from the program and in April 1997 uninsured children under the age of 18 could get Tenncare. There wasn’t any income limit for anyone in this category, but if you were over poverty level, cost sharing was required. In May 1997, enrollment was opened to dislocated workers, who were defined as people who lost work through a bonafide plant closing. By January 1998, uninsured children’s category was extended to 19 years of age with same rules applying as before. Also if parents had insurance, had a family income 200% below poverty level, and the children did NOT have insurance, they could get insurance. If income was above that level, cost sharing was need in family. Xantus, one of third largest medical care organizations, was placed in receivership under Tenncare by March 31, 1999. Prudential, a small medical care organization, gave notice in June 1999 that it would be leaving Tenncare. It only served people in the Shelby County area. By November 1999, Xantus was struggling to pay health care providers for participants in its programs so the state of Tennessee gave it $26 million as a loan to pay providers. By December 1999, Blue Cross Blue Shield, one of TennCare’s largest Medical care organization gave notice it was leaving but it withdrew its termination. By January 2000, the governor, Sundquist arranged a 17 member commission on the future of Tenncare to figure out what to do when Tenncare waiver expired in 2001. By March 2000, Sundquist hosted a summit on the future of Tenncare to gather ideas from hospital executives, doctors, managed care executives and tennessee lawmakers to get ideas for the program in the near future. A man named John Tighe proposed the idea of Tenncare II. It outlined a business model that called for more accountability in the program in May 2000. Also during this time, Tenncare had been approved for children heald under state custody(foster care; children removed from homes). By July 2000, pharmacy benefits for dual eligibles were taken out of the MCO program. This meant that if you were trying to use benefits in two different Tenncare related programs, you couldn’t use two at the same time to get certain medicines. By September 2000, multiple MCO’s denied the implementation of Grier to be appealed. By November 2000, Commission on the Future of Tenncare presented its ideas to the governor. By July 2001, Tenncare acquired two operational MCOs: Better Health Plans and Universal Care. By July 2002, Tenncare was altered in the following matter:
“TennCare was revamped with the intention of dividing it into three programs: one for Medicaid eligibles (TennCare Medicaid), one for demonstration eligibles (TennCare Standard), and one for low income persons who needed help in purchasing available insurance (TennCare Assist). Each of the programs was to have a separate benefit structure.
TennCare Assist has not yet been funded, and the TennCare Standard benefit package has not been implemented due to a settlement agreement reached in Federal Court. All persons enrolled in TennCare currently have the same package of benefits.
Eligibility changes in the new program included the following:
• A new Medicaid eligibility category was added. This category covered uninsured women under the age of 65 who had been determined by a Centers for Disease Control (CDC) site to be in need of treatment for breast or cervical cancer. There was no income limit on this category for Medicaid, although CDC required that women receiving screenings at a CDC site have incomes below 250% poverty. Medicaid eligibles have no cost-sharing requirements.
• The category of "Uninsurables" was replaced by a category called "Medically Eligibles." New persons can enroll in this category if they do not have insurance, they meet "ME" criteria, and their incomes are below the poverty level. Medical eligibility must be proven through a medical underwriting process, rather than being proven simply by a "turn-down" letter from an insurance company.
• The definition of "Uninsureds" was tightened by providing a more restrictive definition of the term "insurance." Certain groups of uninsured people who were already on TennCare were "grandfathered" into the new program.
• Persons losing Medicaid eligibility or already enrolled in TennCare in some other category on July 1, 2002, were allowed to remain on the program if they were uninsured AND their incomes did not exceed 100% poverty for adults and 200% poverty for children OR if they were determined to be "medically eligible" at any income level.
• New enrollment in the Uninsured category was closed. Provisions were made for an annual open enrollment period for low-income people in this category, depending upon the availability of legislative appropriations.
• A process called "reverification" was begun whereby all persons in the demonstration population were asked to make appointments at the Department of Human Services so that DHS could determine whether these individuals were eligible for Medicaid, eligible for TennCare under the new criteria, or no longer eligible for TennCare under the new criteria.”(Citation: tn.gov)
Figure 1: Example of some of TennCare's programs
By October 2002, Tenncare had acquired dental care benefits. All Pharmacy services had been moved to one Pharmacy benefits manager by July 2003. By 2004, more regulations were placed over pharmaceuticals and adults in the uninsured category. Children who were uninsured got to keep same benefits while restrictions were made more tightly around adults, especially eligibility into the uninsured category. Another reform called TennCare Transformation was proposed in 2004, but unless certain modifications were made, it was not going to get enacted. The governor did not want to pursue these modifications, so he was planning to drop Tenncare as a whole and just focus on Medicaid, but he did not want to leave children without benefits. In 2005, they closed the non-pregnant adult medically needy category of its programs because of expenses. In 2006, they broughtthis program back by creating an initiative to lower spending. In 2008, home health and nursing services were limited. By May 2009, re-verification forms were set in place so that TennCare can determine on a yearly basis if enrollees are still eligible for program. For those who lost eligibility, they still had benefits through MediCare. In February 2010, Affordable Health care Act was passed, which greatly impacted Tenncare. In the same month, TennCare submits Amendment nine for requests in benefit reductions and elimination of most adults participating in Tenncare. TennCAre choices in Long-Term Care program was available for people in Middle Tennessee by 2010. It provided community and home based services for people in need. The General Assembly had also passed in 2010 a hospital assessment for hospital that will generate revenue for TennCare because of the recession. By May 2010, TennCare had more than enough revenue to survive, so Amendment 9 was no longer necessary. By December 2010, Tenncare implements Public Hospital Supplemental Payment program, which was passed by submitting Amendment 11. By February 2011, Tenncare submits Amendment 12 to limit adults in program to state budget. By July 2011, Tenncare began covering medically approved smoking cessation products. Previously the benefits were only for pregnant women and people under age 21. By November 2011, surveys were done on TennCare. It was discovered that it had 95% participant satisfaction. Over the years TennCare keeps accepting applicants in their Spend Down program for people in need of health insurance.
Some statistics from the Healthcare and Finance Administration FY 2015 Budget presentation(http://www.tn.gov/tenncare/forms/HCFAbudgetFY15.pdf)
Figure 2: TennCare overall use in 2014
Figure 3: Estimate Increase in costs for 2015
Figure 4: Participant Satisfaction