Tennessee Race for Medicaid: Dial Fast and Try, Try Again


Nathan Morgan for The New York Times

John Orzechowski, a client advocate with the Tennessee Justice Center, called for more than an hour and was successful in advocating for six clients.

Published: March 24, 2013

NASHVILLE — Two nights a year, Tennessee holds a health care lottery of sorts, giving the medically desperate a chance to get help.

State residents who have high medical bills but would not normally qualify for Medicaid, the government health care program for the poor, can call a state phone line and request an application. But the window is tight — the line shuts down after 2,500 calls, typically within an hour — and the demand is so high that it is difficult to get through.

There are other hurdles, too. Applicants have to be elderly, blind, disabled or the “caretaker relative” of a child who qualifies for Medicaid, known here as TennCare. Their medical debt has to be high enough that if they paid it, their income would fall below a certain threshold. Not many people end up qualifying, but that does not stop thousands from trying.

“It’s like the Oklahoma land rush for an hour,” said Russell Overby, a lawyer with the Legal Aid Society in Nashville. “We encourage people to use multiple phones and to dial and dial and dial.”

The phone line opened at 6 p.m. on Thursday for the first time in six months. At 5:58, Ida Gordon of Nashville picked up her cordless phone and started dialing. Ms. Gordon, 63, had qualified for TennCare until her grandson, who had been in her custody, graduated from high school last spring. Now she is uninsured, with crippling arthritis and a few recent trips to the emergency room haunting her.

“I don’t ask for that much,” Ms. Gordon said as she got her first busy signal, hanging up and fruitlessly trying again, and then again. “I just want some insurance.”

Gov. Bill Haslam, a Republican, has indicated that he will decide this week whether to support an expansion of Medicaid to cover more low-income adults, as called for in the federal health care law. Doing so would add more than 180,000 people to the TennCare rolls by 2019, according to the state, most of them adults like Ms. Gordon whose incomes are within 138 percent of the federal poverty level.

Ms. Gordon said she and her husband, who was injured on the job decades ago and is on Medicare, live mostly on his disability check of about $780 a month.

TennCare already provides health coverage to 1.2 million people, more than half of whom are children, at a combined state and federal cost of about $9 billion a year. Many in the Republican-controlled legislature, which includes a strong Tea Party element, opposes its expansion even though the federal government has promised to pay the full cost for the first three years and 90 percent after that.

Opponents of the health care law here, as in other states, say Washington cannot afford to keep that promise. In Tennessee, the debate over expansion is particularly contentious because of TennCare’s tumultuous history. It was once among the most generous Medicaid programs in the country. But costs spiraled, and 170,000 people were cut from the rolls in 2005 under Gov. Phil Bredesen, a Democrat. It was a painful episode that Mr. Haslam said was “weighing on a lot of people’s minds.”

Ms. Gordon hopes to qualify for a program known as a “spend down” — in which a patient’s qualifying income is determined after they subtract their medical costs from their total earnings. The program covers only a tiny portion of TennCare recipients — about 1,000 people, at a cost of $32 million a year. It is also something of an anomaly: while other states have similar programs, most do not limit the enrollment period to brief and infrequent call-ins. Advocates for the poor say the frenzy for the spend-down program is a reminder of the acute need for health coverage everywhere.

“At the end of the day, huge numbers of desperately ill people are being left out in the cold,” said Gordon Bonnyman, the executive director of the Tennessee Justice Center, an advocacy group for families in need that focuses on access to health care. “And that is a story in every state.”

Kelly Gunderson, a TennCare spokeswoman, said that the spend-down program had enough money to cover 3,500 people, but that only about 1,000 were enrolled at any given time because the screening process was so complicated. The screeners, she said, must examine medical bills and records, among other duties.

About 500 people are found to be eligible for the program each time the state opens the phone line. The line has opened six times since the program started in 2010.

Technical glitches can thwart callers’ chances. According to the Tennessee Department of Human Services, which operates the phone line, callers did not start getting through until 6:38 p.m., and 2,500 calls, the maximum, had been received by 7:23. The department is investigating what caused the glitch, a spokeswoman said.

“People started calling here panicked and crying,” said Michele Johnson, a lawyer with the Tennessee Justice Center. “We told them, ‘Just hang on, keep trying.’ ”

Adrian Casteel of Nashville, who said he owed $6,000 in medical bills, said he repeatedly got a recorded message but kept dialing. Mr. Casteel, 55, has a heart condition and a steel plate in his back, the result of a car accident years ago that left him in constant pain and unable to work. He has been on Medicare for nine years because of his disability, he said, but about 20 percent of his expenses are not covered.

“When you see as many doctors as I do,” he said, “that’s quite a bit.”

In her small brick home on the city’s north side, Ms. Gordon also heard the recording that enrollment was closed. But she, too, persisted, never looking up from the phone in her hand. Dusk fell and the room grew dark; she was too focused to bother turning on a light.

She had called about 50 times when, at 6:40, she got through. The woman on the other end of the line asked for Ms. Gordon’s name, birth date, Social Security number, telephone number and address. Ms. Gordon wrote down a confirmation number, thanked her and hung up. The application, she was told, should arrive in a few weeks.

“I still don’t know if I’m getting in,” she warned her husband, Arthur. “If it’s meant to be, it’s meant to be.”

If she is rejected for the spend-down program, Ms. Gordon said she would wait until next year, when President Obama’s health care law is supposed to make insurance more accessible to millions of low- and middle-income Americans. She does not know specifics, like the possibility that she could be covered by an expansion of Medicaid or qualify for federal subsidies to help cover the cost of private coverage. But she said she would eagerly pay what she could for insurance if it was within her limited budget.

“I can’t pay no $200, $300, $400 a month,” Ms. Gordon said. “But I’ll figure out how to pay something if I got to. I’ll squeeze.”

Link:  http://www.nytimes.com/2013/03/25/us/tennessee-holds-health-care-lottery-for-the-poor.html?ref=abbygoodnough&_r=0

Will Health Exchanges Make Insurance Agents Obsolete?

By Lynn Hatter | wsfu.org


Insurance exchanges coming in 2014 will allow individuals and small businesses to compare and shop for health plans. This will be done online, and it means people can bypass traditional insurance agents and go straight to the product.  And that has health insurance agents concerned, because they make money on commissions – and they wonder what their role will be.

“Well, that’s a great question [laughs] and frankly, most of us don’t know the answer, in the context of the exchange,” says Kyle Ulrich, Senior Vice President of Public Affairs for the Florida Association of Insurance Agents.  

Right now, state-licensed agents work with consumers and businesses, earning commissions on what they sell. The federal health law outlines a different group of workers called “navigators” to do a similar task on the insurance exchanges, and that service is free for the shopper.

“That individual market place, for agents who occupy that space, it’s a scary time, because they see the typical distribution channel  through agents being troubled when we start talking about these exchanges and so forth, and the health insurance product becomes very commod-itized,” said Ulrich.

But health insurance agents say it’s not just about the money. They’ve have had extensive training. They have to be insured to make sure they don’t give bad advice, and if they do, they can be sued. That’s not true for navigators, and FAIA’s Urlich says the issue is largely about protecting consumers.

We don’t have a problem with navigators being there to help folks sign up for the exchange. That’s what they’re there for and that’s fine. What we firmly believe is that they’re not there to sell insurance. And to the extent that there might be conversations between a navigator and a consumer that goes outside that purview, we believe there should be an enforcement mechanism.”  

The insurance industry is pushing states to place additional regulations on the navigators. Even though Florida has decided to let the federal government run its exchange, Florida will still have a say on regulating the people who will work behind the scenes in those marketplaces.

“Our idea would be to let the Department of Financial Services to issue a license,” said Tim Meenan, with the National Association of Insurance and Financial Advisors, said in public testimony before the Senate Select Committee on the Patient Protection and Affordable Care Act.

“Make them take some training. If they do something untoward toward a customer, you can put them out of business. And frankly, we think they should be required to only talk to people who are uninsured.”  

Insurance agents want the navigators to defer to them when it comes to helping consumers make purchasing decisions, and they say they’re confident they’ll get some regulations in Florida. States like Virginia, Ohio and Utah have legislation pending that would place strict regulations on the navigators. But one area the state won’t have a say in, is who gets to sign up to be a navigator.

“The navigator program, it’s not that they’ll be selling insurance product. It’s designed to be an outreach assistant. To help people understand, to “navigate” the new system,” argued Karen Woodall, a lobbyist and Executive Director of the Florida Center for Fiscal and Economic Policy. 

She says it will be up to the federal government to pay for, and register, those navigators. And she disagrees with insurance agents who say the navigators should be subject to additional state rules and regulations, because they won’t be performing the same tasks.

“It is a program that will be monitored by the federal government.  You will have to apply. You will have the training, just as other people who are giving information through outreach,” she said.

“The intent is, we focus primarily on community-based organizations where people have a relationship and trust. It’s not something anybody signs up for and doesn’t have to have training, and that they’ll be trying to coerce or encourage people to buy a particular product.”   

Groups like local chambers of commerces, unions or consumer-advocacy organizations can sign up for the navigator program. Navigators will be paid through fees imposed on insurers through the exchanges. The federal government will give out grants to groups to fund the navigators. The health law says navigators can only be paid for helping with enrollment, and not on the commission-based pay system that insurance agents usually work on. And that means health insurance agents can’t sign up to be navigators, and navigators can’t be health insurance agents.


Article Link: http://news.wfsu.org/post/will-health-exchanges-make-insurance-agents-obsolete

Medicare-Medicaid Dual Eligibles: Measuring Quality of Special Needs Plans and State Demonstrations


Published on 21 March 2013


Medicare-Medicaid dual eligibles are often held up as a prime case for the need for better care management to reduce health costs and spending while improving quality.  But doing so can be challenging.  Most dual eligibles have multiple health conditions, whether a chronic disease, severe cognitive or physical disabilities, or some other condition or impairment that requires long-term care.  About 40 percent of dual eligibles have both a serious physical health diagnosis and a severe behavioral health condition, making care coordination and quality improvement all the more important and challenging.

Those interested in how current health insurance programs for dual eligibles measure quality can turn to a recent brief from the Center for Health Care Strategies (CHCS). You can read the full brief at the CHCS website – www.chcs.org – but here are some highlights.


Special Needs Plans for Dual Eligibles (D-SNP):

D-SNPs, part of Medicare Advantage, account for more than 80 percent of, or 1.2 million, Special Needs Plan (SNP) enrollees. A report last year from Government Accountability Office (GAO) pointed out that the Centers for Medicare and Medicaid Services (CMS) does not require D-SNPs to report a standardized set of outcomes.

Nonetheless, the CHCS brief pulls some helpful examples of different quality measures D-SNPs use:


Most of the data come from Healthcare Effectiveness Data and Information Set (HEDIS), though some come from the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS), or from CMS directly.


Quality in Financial Alignment Demonstrations for Dual Eligibles:

The Affordable Care Act (ACA) health reform law opened the door for CMS and states to launch integrated Medicare-Medicaid health plan demonstrations. Long-term care use, mental health service use, quality of life, and care coordination are of particular importance in measuring quality of care demonstration programs provide.

Examples of quality measurements for the managed care integrated dual eligibles demonstrations include:

  • Success managing complex cases, evaluating access to case management, individualized care plans, satisfaction with case management, and identifying members who would benefit from case management.
  • Easing Care Transitions, which looks at how well health plans manage and improve care transitions from hospitals to long-term care, for example.
  • Coordination of Medicare and Medicaid benefits, which includes service coordination and network adequacy assessments.


Business Briefings for Health Plans on Integrated Care Demonstrations:

Sellers Dorsey recently hosted two helpful webinars on dual eligibles: one is a basic overview and the other describes business opportunities and risks for health plans in the large and growing dual eligibles market.

In the later, Mike Fox and Kip Piper of Sellers Dorsey provide a 90-minute briefing for health plan executives on the new demonstrations to integrate Medicare and Medicaid financing and care delivery for dual eligibles. Mike and Kip describe the current $350 billion dual eligibles marketplace, state plans to contract with health plans, steps health plans should take in assessing the business opportunities and risks of serving this market, and key considerations for entering the integrated Medicare-Medicaid health plan business. Watch the briefing online for free here on Vimeo.


Read more Piper Report posts on dual eligibles issues here.


Article Link: http://www.piperreport.com/blog/2013/03/21/medicare-medicaid-dual-eligibles-measuring-quality-special-plans-state-demonstrations/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+PiperReport+%28Piper+Report%29