Health Care Delivery System
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.
TennCare services are offered through managed care entities. Medical, behavioral and Long-Term Services and Supports are covered by “at-risk” Managed Care Organizations (MCOs). All of TennCare’s MCOs have recently been ranked among the top 100 Medicaid health plans in the country. The care provided by TennCare’s MCOs is assessed annually by the National Committee for Quality Assurance (NCQA) as part of the state’s accreditation process.[1] In addition to the MCOs, there is a Pharmacy Benefits Manager for coverage of prescription drugs and a Dental Benefits Manager for coverage of services to children under age 21.
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.
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.
TDH Efforts for Outreach and Enrollment
TDH has undertaken several efforts to assist clients seeking services in public health departments to access public insurance or insurance available through the health insurance marketplace. In the 89 rural counties, there are at least two (and in many cases more) options for obtaining assistance with Medicaid and ACA insurance enrollment. TDH clinic management staff can provide clients with information (verbal and written) about how to access enrollment assistance for these plans. In all clinic sites, TDH staff provides presumptive eligibility determination for Medicaid for pregnant women and for individuals diagnosed with breast or cervical cancer.
A map was developed in 2014-15 that indicated the locations of state agencies and partners across the state who could assist with insurance enrollment and outreach. The map and list of referral sources was shared with both local and regional health department leadership. Local staff have this map and resource listing as a tool to assist patients in finding navigator and application assistance services.
Clinical Application Coordinators (CACs) are also available in 16 counties (Stewart County, Gibson County and all 14 counties of the Upper Cumberland Region) as well as in metro health departments. These CACs provide outreach and on-site enrollment services in communities across the state for marketplace plans. Additionally, the TDH Breast and Cervical Cancer Screening Program (partially funded by Tennessee’s MCH/Title V Program) and the Ryan White HIV/AIDS Program each have one CAC in each rural region to assist with outreach and on-site enrollment efforts. Care coordinators for CSS also assist with enrollment through the marketplace and with appeals for third-party payer denials.
In 2018 (CY), TDH assisted 17,980 pregnant women with presumptive eligibility assistance and 14,313 pregnant women with Medicaid and CoverKids enrollment assistance. TDH conducts routine training with local staff on changes in the Medicaid enrollment process to ensure that eligible persons can be served.
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 has piloted increasing the income eligibility to 225% of federally poverty level in one region successfully.
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 CY2018, 77% of individuals served through the program were at or below 100% of the federal poverty level and 97% 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 5.2% (43,359) of TennCare EPSDT visits in the state in FFY 2018. 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.
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