Tennessee’s modern efforts at health reform began in 1994 with the introduction of TennCare, Tennessee’s Medicaid program.  Given the significant overlap in priority population and the opportunity for population health improvement, TDH partners extensively with the agency. The TennCare program operates under a Section 1115 waiver from the Centers for Medicare and Medicaid Services (CMS) in the United States Department of Health and Human Services. Unlike traditional fee-for-service Medicaid, TennCare is an integrated, full-risk, managed care program.

TDH has developed arrangements whereby traditional public health services, including family planning, STI screening and treatment, EPSDT, and tuberculosis screening and treatment are provided in county health departments and generally reimbursed without a primary care provider referral.  TDH has current Participating Provider Agreements with all three TennCare (Medicaid) MCO plans (Amerigroup, BlueCare, United Healthcare Community Plan), DentaQuest (TennCare dental), Magellan (TennCare pharmacy), Humana (private insurance), Cigna (private insurance), Aetna (private insurance), Oscar Health Plan (ACA marketplace), Bright Healthcare (ACA marketplace), Medicare (flu/pneumonia credentialed in all county health departments and all Federally Qualified Health Centers are credentialed part A providers), and Blue Cross Blue Shield of Tennessee (ACA marketplace and private insurance).  Traditional public health services (i.e., family planning, STI screening and treatment, EPSDT, tuberculosis screening and treatment, vaccines) are billable to these third-party plans. In most cases, these services are available to third party plan members without a primary care provider referral.

TDH continues to partner with the TennCare MCOs to set up an electronic portal for referral of pregnant women who smoke to connect them with cessation counseling and incentives which are billable services reimbursed by the MCOs. TDH was able to prove efficacy of this model with state tobacco prevention funds and then partner with the MCOs to sustain this important public health intervention as a billable service. This has been a significant achievement for TDH, TennCare, and the MCOs.

Over the past five years, the Department has greatly expanded its ability to bill third party insurance by negotiating contracts with carriers. Nonetheless, the state has been significantly impacted by increasing premiums in the federally run health insurance marketplace. There are three marketplace plans in the state, and increasingly only one plan is offered in any given area. State and federal discussions are rapidly evolving and have the potential to dramatically affect insurance coverage and access for Tennesseans.

Partnership

The scope of MCH/Title V partnership with TennCare extends far beyond reimbursement for MCH services in local health departments.  The agencies partner together in multiple population health priorities.  For example, TennCare partially funds infant mortality reduction initiatives through MCH/Title V programs such as group prenatal care pilots, FIMR teams, safe sleep promotion, and training in long-acting reversible contraception insertion.  TennCare representatives routinely participate in the Perinatal Advisory Committee to discuss issues such as delivery at appropriate levels of care, implementation of the LOCATe tool, NAS management, and back transport policies. TennCare, TDH, and the MCOs also meet at least quarterly with the Tennessee Chapter of the American Academy of Pediatrics to coordinate efforts around EPSDT, immunizations, PCMH, and emerging population health priorities. In addition, the MCH/Title V director meets regularly with TennCare in context such as the NAS subcabinet, TIPQC, and on an ad hoc basis.  TennCare has intentionally included input from TDH and the MCH/Title V Program regarding the implementation of its episodes of care model for payment reform.  TennCare funding also supports TDH outreach efforts and partially supports the HUGS care coordination services, and TDH has worked extensively with TennCare and the MCOs to align service delivery via CHANT.  The agencies collaborate on multiple other MCH related efforts such as lead screening and EPSDT outreach. There has been ongoing joint action to minimize barriers to contraception and particularly voluntary long acting reversible contraception in the immediate post-partum period, co-authorship of the legislatively mandated diabetes report, co-authorship of a 2017 legislatively mandated report on neonatal abstinence syndrome, joint work around maternal mortality reduction initiatives, and support for the perinatal quality collaborative roll out of its quality bundles for substance exposed mothers and neonates.

New Innovative Health Care Delivery Models

TennCare is seeing positive results from several changes it has made to how health care is paid for and delivered in Tennessee. The state’s innovative programs are resulting in improvements in the care of TennCare members, as well as significant programmatic savings. Tennessee's Health Care Innovation Initiative is moving from paying for volume to paying for value.  The mission is to reward health care providers for high quality and efficient treatment of medical conditions and help maintain member’s health over time.  Tennessee is leading by example through the TennCare program and Tennessee state employee’s benefits administration in hopes other stakeholders are asked to join in statewide payment and delivery system reform.

The Tennessee Health Care Innovation Initiative has three strategies, primary care transformation, episodes of care, and long-term services and supports.  Primary care transformation focuses on the role of the primary care provider in promoting the delivery of preventive services and managing chronic illnesses over time. The initiative has developed an aligned model for Patient Centered Medical Homes (PCMH), Tennessee Health Link for TennCare members with the highest behavioral health needs as well as a shared care coordination tool that allows providers to identify and track the closure of gaps in care linked to quality measures.  Episodes of care focus on the health care delivered in association with acute health care events such as a surgical procedure or an inpatient hospitalization. Episodes encompass care delivered by multiple providers in relation to a specific health care event.  The long-term services and supports (LTSS) component focuses on improving quality and shifting payment to outcomes-based measures for the QuILTSS program and for enhanced respiratory care.

MCH/Title V Funding for Gap-Filling Health Care Services to MCH Populations

Tennessee continues to use MCH/Title V funding to provide gap-filling services to MCH populations. Examples include:

Children’s Special Services:  MCH/Title V funding supports care coordination as well as reimbursement for direct services (inpatient/outpatient hospitalizations, physician office visits, laboratory testing, medications, supplies, durable medical equipment, and therapies). Payment for medical services is available for children with a chronic physical diagnosis whose family income is at or below 200% of the federal poverty level. in 2017, CSS piloted increasing the income eligibility to 225% of federally poverty level in one region successfully. As of January 1, 2020, income eligibility has increased to 225% statewide.

Breast and Cervical Cancer Screening:  MCH/Title V funding is used to support screening and diagnostic services for uninsured or underinsured women at or below 250% of the federal poverty level. This funding augments other federal funding (CDC) as well as dedicated state appropriations and funding from the Susan G. Komen Foundation.

Family Planning:  MCH/Title V funding augments federal Title X funding, state appropriations, and patient billing collections. In CY 2020, 70% of individuals served through the program were at or below 100% of the federal poverty level and 96% were at or below 250% of the federal poverty level.

EPSDT:  MCH/Title V funding provides funding for EPSDT visits for uninsured children in local health departments. Likewise, children seen in WIC, immunization clinic, or adolescents in family planning clinics are offered EPSDT services if desired by the family in cooperation with TennCare to increase screening rates across the state. TDH provided 31,453 of TennCare EPSDT visits in the state in CY 2020.  TennCare, TDH, and the MCOs share data to outreach to target counties to increase adherence to the AAP periodicity schedule. TDH is enhancing efforts to connect EPSDT visits to the medical home via CHANT pathways.