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TennCare hopes to open new eligibility category

TERESA HICKS • Jan 30, 2007 at 10:48 AM

State officials are planning to open a new TennCare eligibility category for 100,000 people in the coming months, provided that talks with the U.S. Centers for Medicare and Medicaid Services go well.

According to TennCare spokeswoman Marilyn Wilson, the Bureau of TennCare is planning to create a category called standard spend-down. Similar to the old medically needy spend-down category, standard spend-down would be available for people who make too much money to qualify for Medicaid benefits but who have accrued enough medical bills that the amount left over is low enough to qualify them for Medicaid.

"For a single individual, you would need to spend your income down to $241 a month," Wilson said. "For a family of two, it's $258. For a family of four, it's $325."

Unlike the medically needy spend-down category, however, the new standard spend-down benefit would have a strict time limit. Coverage would only be available for one year.

"This is a very narrow eligibility category," Wilson said. "It exists for the situation when someone has an episode that runs up high medical bills quickly. That's also one of the reasons why you see it as a temporary category. It's really supposed to help the individual over that medical episode and help cover the intense medical expenses that they have and recovery expenses."

When the TennCare reform process began in 2005, enrollment in the medically needy spend-down category was frozen, but no one was actually disenrolled from that program. At the time, there were 97,000 Tennesseans receiving benefits through medically needy spend-down. Today, that number has dwindled to about 50,000 for various reasons, Wilson said.

"We have had people who have moved. We have people get sick and pass away," she said. "Just through the normal course of a year, we've had people come off of the category, but not through disenrollment."

Those remaining 50,000 will not automatically be enrolled in the standard spend-down category, but will instead have to reapply for coverage. Some will qualify; some will not.

"It's possible that some of the people that are in the category now could quickly acquire unpaid medical bills and would have the opportunity to come back on the program," Wilson said. "They actually have the opportunity to reapply for Medicaid in another category or they can come back into the standard spend-down category once it reopens."

Wilson said there is no set timetable for beginning enrollment in the new standard spend-down category. TennCare officials are still waiting for word from the federal government on whether they will be allowed to make the change.

"We asked permission from CMS to let us open the category, and while they said that they agreed we should open the category, in the same letter, they did not approve our waiver extension for the TennCare program, which expires in June of this year," Wilson explained.

"There's a Medicaid rule that says you can't open a waiver category six months before your waiver is going to expire.

"We have to finish the negotiations with our waiver extension, which we are actively doing with CMS right now. We won't be able to open the category until that waiver extension has also been approved. There are no regulatory time frames around when CMS can give their approvals."

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