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Why the services of the state Medicaid program is cutting TennCut: thousands of people with disabilities
Thyroid disease, congestive heart failure, blood clots, anemia and rheumatoid arthritis are just some of the health problems Memphian Ann B. wakes up every day. For 11 years, has been covered by TennCare consultation called Social Security, or the "Daniels" class. Ann asked that his name is kept anonymous.
In 1987, a group of patients – to identify the name of one of the plaintiffs, Daniels – TennCare filed a lawsuit claiming he was dropping his services without just re-assess their eligibility.
So the U.S. Federal District Court in Nashville issued an injunction in November 1987 prohibiting TennCare re-evaluation of eligibility patient until officials TennCare Daniels found a way to improve the process of case on file sat for over 20 years.
In January, Judge John T. Nixon of the U.S. District Court for the Middle District of Tennessee raised injunction against TennCare. Since then, patients in class have been SSI getting TennCare re-evaluation of the forms (often called "pages of peach in color) to determine if it is eligible for the category.
Patients with SSI are by definition TennCare, the low-income people who are elderly, blind or disabled. Ann falls into that category. Her husband also is disabled and receives benefits from the Veterans Administration. They live on Social Security only.
Some call the SSI / situation Daniels "cuts." Some call it "re-evaluations." Anyway, from 2 October, the most recent numbers of TennCare had been approximately 147,000 SSI patients who had been covered for 22 years, some 84,000 have lost their coverage in the pages of peaches began dating earlier this year.
Currently, 63,000 patients are still receiving benefits; 40,000 of these patients have completed the reverification process and can remain on SSI or be moved to another category, TennCare spokeswoman Kelly Gunderson. The other 23,000 patients are "in process", he said, meaning the decision being appealed TennCare still have not received their notices, or still have time to send in your information.
The media have come to the news of the "Daniels" courts as is the scandal of a lifetime. But changes are not affecting TennCare patients only in the kind of SSI. Cutting services and cutting other patients in other categories – which also include the severely handicapped or sick people who need constant or nearly constant care – have as profound an impact on those who could be facing life in a nursing home as soon as next year.
Life and death
Ann did not know the name of the class that was in Like many people, she only knew she had TennCare.
At 62, Ann is based in 12 to 15 medications a day plus regular laboratory visits and medical appointments to not only stay healthy, but alive.
When news of Memphis called to speak with Ana, who was too ill for interview in person. She had been in bed for days with an upper respiratory infection, and after re-evaluation of SSI status this year – and its subsequent reduction of the class – who could not afford to see a doctor.
Ann said the loss of TennCare coverage is "like being sentenced to die."
"It would be different if we are given some tips on what to do instead of Just closing the door and saying, 'That's all." I mean, if I do not take my medicine, I'm dead, "Ann said as she coughed.
Ann had been in TennCare until last year. When he received notice in June that would be cut from the SSI ( "Daniels class"), which completes the pages of peach complicated by itself and returned them, only to be rejected. Did appealed – and lost.
"When I was upset, I sent a letter saying I had 63 days to apply for health insurance under the HIPAA (Health Insurance Portability and Accountability Act) plan, which means that you are covered with pre-existing conditions, but each company that was sent me $ 1,000, $ 2,000 a month, "Ann said. "The cheapest I found was about $ 600 a month."
Ann Social Security income is less $ 700 a month, and her husband is just enough to pay the phone, mortgage and other necessary bills. She does not qualify for Social Security disability, said, because she left work too early fiscal quarter.
"And I had been working all my life," said Ann. "That's what they said, that's what I got. It's just close the door in my face again. "
Right now, Ann is busy applying for charity whenever she can. Partnership for Prescription Assistance, a national program, is helping her salary for two of his recipes. She receives treatment through the Regional Medical Center Memphis for rheumatoid arthritis, and as applied to the charitable program there, she has not yet been approved.
"They have agreed to continue seeing me, but go to an invoice so I can not afford, "he said." But I've applied for charity, and Jennifer (Tlumak) into (the Tennessee Justice Center) helped me get the forms from the DEM. It takes forever to get any answers or responses, but eventually, after working there for long time, I sent the forms. "
Your primary care physician is also trying to help her get charity care to through that office.
While she was on TennCare, she said it was very well kept.
"I could go to the doctor, and paid for it, who paid for my lab, who paid for five prescriptions per month. There were several who had to wear, but most of them are $ 4 because they are generic, so was capable of doing everything myself. But since I have taken, of course, I can not, no way I can afford it.
"It's hard for me to say anything bad for them because they look after me for 11 years, but … "Ann went out.
Ann knew nothing about the local legal clinics Memphis Area Legal Services Inc. is offered in conjunction with the Tennessee Health Campaign and TJC. She was the only patient Memphis news spoke to a lawyer who has no help problem with TennCare.
'The same process'
To qualify for SSI, or Daniels, a patient must have a monthly household income of no more of $ 674 a person or $ 1,011 for two people with a resource limit of $ 2,000 and $ 3,000 respectively. The resource limits include savings, trust and other financial resources are not identified as ordinary income.
SSI is a category of mandatory Medicaid eligibility, which means TennCare is required to offer this class and meet the people who qualify.
Gunderson emphasized the re-evaluation of SSI is "going through the same process that all the world is. "
"Either you are eligible or not eligible for the program," he said. "And this is the same process we do every year for other members. This was just a group of people who, in some cases, never went through the process of (annual) to see if they still qualified for the program (after the court order was made). "
Federal mandate requires state Medicaid programs like TennCare to evaluate their patients in at least an annual basis if not more often. Tennessee evaluates each patient once a year.
Gunderson said the SSI category is still open.
"This category of SSI, which is still there for people who receive income from SSI," she said. "What happened was that we had these people remnant that remained in that category that could not be verified as we do in all our categories. … We have to do that for the integrity of our program. "
TJC Management Lawyer Michele Johnson said one problem with the additional verification that SSI is not done well enough and many people never received Peach their pages.
"(One) reason why this process has never been put in place for 20 years is that the TennCare computer system is not reliable enough to maintain the right direction for people, "he said." New Directions, current addresses, given by the member TennCare are canceled by the old addresses because the TennCare computer system has to talk to the (Department of Human Services), computer system, you need to talk to Safety Social system. And the result is that it comes to eating well, so many people do not receive proper notice.
"We have many calls from people not find out until they go to the doctor … or pharmacy. That is illegal, and must re-register immediately. They should be given the opportunity to prove they are eligible. "
Gunderson said TennCare provides that right. She said TennCare sends notices to all known addresses for a person to four.
"Will to pass that sent us a page that someone did not get peach? Yes, but that's why we have the appeals process in place, so if someone came went to his doctor and said, 'Oh, what do you mean, I have no TennCare? that can go through the appeals process. If they can prove they sent the wrong direction, so we have to (appeals) process, and during that process, you maintain the benefits. "
But there is another problem: If a patient is notified of SSI losing their coverage, they have 20 days from the time you receive your initial notice of appeal, and if they use during that time, coverage will continue. After 20 days is, the patient has another 10 days to file an appeal, but the services will be suspended during that time. That is the standard timeline for all appeals of changes in TennCare coverage.
In theory, if a patient does not know his TennCare went up 20 days on the line, their services can be cut. If after discovering that fact in time to file an appeal within 10 days of the period of 20 final days, its services will be closed to them during the appeals process – and possibly could not be replicated in all, unless the patient could be, without indeed, the pages were sent to the wrong address and was the fault of TennCare or the patient still qualifies under the same or a different category.
Gunderson, emphasized the member's responsibility to notify any state agency of an address change.
But that's not all
People SSI in the class are not alone facing TennCare cuts began this year. TennCare provides a category known as Medically Needy Spend Down category. To qualify, an individual "or must have an income not exceeding the figures provided should be enough … or unreimbursed medical bills to" spend " to these income limits, "according to TennCare.
After paying unreimbursed medical expenses, a single person can not earn more than $ 241 per month. A family of four can not make more than $ 325 a month. There is also a resource limit of $ 2,000 for an individual and $ 3,000 for two people.
Medically Needy Spend Down is an optional Medicaid category, which means TennCare has to offer. The "pass" the level is set by the State.
Atoka Brandon Byrd is a resident who has been fighting one, but two, cases of TennCare coverage. Byrd is a quadriplegic who was injured in 2004 when fell from a trampoline while playing with his two sons.
As a result of injury, Byrd also damaged the trachea, which leads to the necessity a tracheotomy. The initial operation called a tracheotomy is an incision into the trachea, forming a temporary or permanent opening called a tracheostomy. The insertion of a tube into the opening allows the passage of air and removing secretions. For this to be done regularly (especially for a quadriplegic), someone with medical training should be available to perform these functions, or the patient may suffocate and die.
Byrd was injured when he was 24 years old. Met 30 years in November.
Formerly an industrial full-time worker, Byrd was covered by private insurance, when he was injured. After a couple of months hospital, private insurance dropped him. Not long after, I had to get TennCare, a process of his wife, who has since separated from him, took over.
"I've been in TennCare since then," Byrd said. "I was just trying to live, I was not really worried about TennCare. But my wife went through a lot of different things to get TennCare started … she had to deal with paperwork, and lagoons and backdoors. … Everything is so complicated. It is very difficult for someone to get what they deserve ".
Byrd, who had been working since she was 13, began receiving 24 / 7 private home of elderly duty as a member of the Medically Needy Spend Down category. Due to the TennCare assistance was provided, was able to continue to see their children – two boys, between 5 and 11 – at least every two days, and even studied full time.
However, in June 2008, when Byrd began receiving documents that its nursing services at home may be reduced from 24 hours a day, seven days a week, four hours a day, five days a week, he was angry.
"I started to write letters," he said. "In fact, I was desperate. So I started sending letters and I think someone passed it to Justice Center Tennessee, and he contacted me (Linda) Casals. "
Casals is Byrd's attorney through Memphis Area Legal Services. Neither she nor Byrd is unclear why TennCare is trying to cut their services.
To add insult to injury, TennCare is not only Byrd cut services, but the state is also Byrd discussing is not eligible for the Medically Needy Spend Down category anyway, Byrd and Casals said.
Casals said it was "weird" that Byrd was in that category to begin with, because after his six-month stay in hospital after his fall, TennCare put him in that category, but do not have to submit invoices to enter the category as it was created at the time. "
"I'm still confused about this," Casals said.
Casals and Byrd had a hearing in early October to discuss Byrd needed to keep his private nurse. Both are still waiting namely of the state in which the hearing is about keeping any TennCare eligibility.
"I do not hear anything in October, so I guess it will be November "Casals said." I do not know. They have not told any of us yet. "
The Medically Needy Spend Down category Adult is closed to adults, according to the TennCare Web site. Gov. Phil Bredesen froze that category in 2005, just after Byrd qualified to do so.
The State cites budget problems as the reason for cutting TennCare services and categories of closure. In September 2008, Bredesen said in a budget speech tightening as the reason for the service of private home nursing category is shrinking. He said the category is "clearly uses being misused, "as he used the example of a couple, both in TennCare, receiving private duty nursing.
"They live in the same home together and each has a 24 / 7 private nursing-sitting in his living room. At $ 325,000 per year for each of the nurses, "Bredesen said.
But Byrd said he is not abusing the category. His only income is Social Security.
"It's not like I get a lot," said Byrd, who saying that "very pleased" SSI income, except "my children enjoy having food and clothing, and I like to eat too."
Quoting the "pile of papers that all say the same thing," Byrd said, "I do not know what TennCare is trying to say – no," because they have this income Social Security, you do not qualify. But I have enough to pay for this care. "
He even offered an alternative to keep costs of TennCare for care.
"The nurses are here 24 / 7 is expensive," said Byrd. "But I could do with maybe not a licensed nurse all the time – you could probably do with a nursing assistant (staff), half day and half, a nurse – I need someone here who can doctor do things I need. There must be a (licensed practical nurse). "
But if Byrd lose your coverage, or if TennCare cuts in four hours daily from Monday to Friday, it will not be able to stay home.
"No form of private insurance that covers this," he said.
So his only option is a nursing home. In terms of cost, which is actually cheaper for TennCare. Gunderson, confirmed that costs about $ 300,000 year to provide 24 / 7 private nursing home for a patient, while it costs around $ 60,000 a year to put that same patient in a nursing home.
But those figures do not add to the receipt of the same quality of care.
A health worker who spoke briefly to the news in Memphis on condition of anonymity, said, "$ 60,000 a year salary is about a nurse. If someone is paying $ 60,000 a year to care for someone who previously was not only operating, but the improvement in a plan that cost $ 300,000 a year, well, you can see how the quality of care that will house. "
Byrd and getting better. Thanks to physical therapy, has begun to regain some movement in his left arm.
"The first Once I got hurt, I had no movement at all, "he said." Now I am starting to move, the shoulders are really strong, and I'm doing something of motion in my biceps and the elbow of his left arm. If you keep going at the pace going, next year might be able to move my left arm.
While saying that, literally, on one side, also said he does not care.
"All I need an arm. If only I could reach out and touch my children and hug them – or balance point in one direction, "he said. If he stays with minimal or no coverage, no nursing homes in Level II or in Tipton County 60 miles from home, Byrd said he probably will stay home and try to stay alive as long as possible.
"They can not make me go" said. "I would stay home as long as I could. That would probably not longer than a week and a half. But I do not want to go live in a place that could be even worse than jail, where even I can see my children. "
In the meantime, however, Byrd said he expects a positive outcome in your audience coming, and plans to continue going to school full-time business if TennCare continues its coverage.
"I try to do everything I can," he said. "I try to be as much a part of the lives of my children that I, who still think that I'm Dad, I still do everything a father, but is a bit difficult do that in a nursing home somewhere. "
Byrd's commitment to parenthood has not gone unnoticed. Last spring, the TJC honor Byrd, with his Father the Year. Byrd said it was "highly significant" for him as he suffered a difficult childhood himself.
"That was one of my great things even before I got hurt, "he said." I wanted to make sure it was a good father. So get that (award) made me feel good, because I try hard.
Crunching numbers
With the governor and TennCare claiming budgetary reasons, a brief look at the numbers is in order.
TennCare operating budget for fiscal 2009 was $ 7 billion, with $ 576 million in reserves. "The state of the rains" Day of funds sat at about $ 700 million.
The continued decline in sales growth in July tax significance Tennessee experienced a full fiscal year of negative growth, according to press reports. Sales taxes represent about 60 percent of state money. State economists have estimated it will be sooner 2011 Tennessee sees no growth in sales tax revenue.
July, August and September, all income also declined. The latest figures show that income in September, to just over 920 million U.S. dollars, 5.7 percent below September 2008. Not only were sales tax collection coming in around 37.8 million U.S. dollars less than what the state had budgeted, but gasoline / fuel collections and inheritance and property taxes also occurred under the amounts specified.
But the Recovery and Reinvestment Act of 2009 brought $ 1.1 billion to Tennessee. In general, stimulation federal contributed 87 billion U.S. dollars in additional federal Medicaid funding for states.
The law says that the stimulus of increased Medicaid funding will be available to Medicaid spending from 1 October 2008, and December 31, 2010.
Gunderson emphasized that none of the financial incentives was placed in reserve – or TennCare reserves or state emergency account.
But Johnson, the lawyer for the TJC, said that all funds were used to encourage active health care and she said the governor's office put money in reserves.
"Among other things, federal law says states can not to the stimulus money to reserves, either directly or indirectly, "he said." They have to spend the stimulus money and have to spend on care of health. "Another important aspect is that the ARRA for States to qualify for Medicaid fiscal relief, they must maintain the income eligibility levels that were in place on 1 July 2008 and that "can not make it harder for people to apply for or maintain Medicaid, according to a summary of the law FamiliesUSA.org.
States have until July 1 to undo any changes that may disqualify them from receiving the temporary additional Medicaid funding.
The bill also increased the incentive of federal dollars for programs counterpart Medicaid. Before the adoption of the ARRA, Tennessee uses to receive $ 2 from the federal government for every $ 1 the state spends on TennCare. The stimulus bill larger than the matching fund to $ 3 for every $ 1 spent.
"That's what we're going to get about 75 percent of counterpart funds from the U.S. government," said Gunderson. "That used to be around of 65 percent. So (an increase) due to the incentive money. "
With the additional funds to match, temporary help and reserves stimuli Medicaid are among the highest in the country, how can TennCare reduce services or purge people from their rolls – especially as for funding, to Tennessee, the state needs to maintain levels of Medicaid, where they were in July 2008?
"I think the best way to say it, the way it was written in the bill is that the categories of eligibility can not be more restrictive than they were on July 1, 2008, "Gunderson said." And that means, basically, we could not take away from a category of eligibility. And the category of eligibility remains the same (on SSI). There is a change in who is eligible. What has changed is that now they could check to see if people really qualified in that category. "
With regard to the Medically Needy Spend Down category, Gunderson said that 'the important thing to note is that with the encouragement of funding, if we were to make an expansion of Medicaid, would not get that amount major expansion. "
But what happens to a patient as Byrd, whose services are cut and their eligibility challenged?
Gunderson could not deal with specific situations of patients. "Even the much quoted" Myth vs. Reality "page in the TennCare Web site does not explain this phenomenon.
"You know, the whole purpose of the incentive money and saying he could not change the eligibility is that we are in an economic crisis "Johnson said." We want to ensure that states do not use the economic crisis by reducing the health of people, because if they do, they will spiral and pain to the entire community.
"The intent of this provision of the stimulus bill was to freeze all – and would include Daniels people. The conclusion is that everyone would remain the same. "
But Johnson said the law does not say Tennessee could not do what was doing with the category of SSI, or "Daniels" injunction case.
"I think (TennCare) would say that we are not changing the eligibility, because (some of) these people were not entitled, or not anymore, "Johnson said." I think it's more of a technical argument, since never intended that they would send all this money to the states, and then what is happening with these cuts Daniels is one of the biggest cuts in the program Medicaid in the history of Medicaid.
The largest reductions in TennCare were made in 2005 when Bredesen served more than 200,000 people from the lists. In March 2005, the Centers for Medicare and Medicaid Services approved the reform plan Bredesen, but only days later, U.S. District Judge William Haynes Jr. arrested all TennCare cuts until the end of a court hearing to determine whether the state has that right.
In April 2005, a panel of three judges for the Sixth Circuit U.S. Court of Appeals in Cincinnati, said Haynes, overstepped his bounds to stop the state to make the cuts and then TennCare announced plans to reduce enrollment than 323,000 people beginning in the summer of 2005. Some services were also reduced or cut altogether, such as mental health care and treatment addiction.
What next?
Gunderson said TennCare is excited to implement the "Long Term Care Community Choices Act of 2008. TennCare announced in July that federal officials approved changes to long-term care program in Tennessee.
Long Term Care Community Options Program ends slot "mentality, so do not set the maximum number of people can cover TennCare under it, but also the minimum set.
Gunderson said the date of the Elections Act is March 1 for the Middle Tennessee TennCare and implement this west Tennessee and later registration in 2010, "in the first quarter of fiscal year."
"And once the choice program is under way, will change the way you run the program but still have people to stay home with the home – and community-based services, "he said.
Previously, "… we had this waiver from the federal government, and we … 6000 waiver slots in which the entire state to serve people who stay at home in the Home and Community [Services] resignation, "said Gunderson.
The slots in the Home and Community Based Waiver services, Gunderson said it opened its doors in October, there was after CMS approved an amendment to a federal waiver allowing TennCare managed care organizations (MCO) to coordinate all of a member of TennCare needs. The new exemption allowed 6,000 slots.
HCBS has allowed "a record number of people – about 6,000 Tennessee – otherwise would require nursing home care are instead receiving Home and Community Based Services (HCBS), reserving the quality of health care services they need in their own homes instead of being treated in a nursing facility "according to a press release from TennCare.
Gunderson said that of the 6,000 "slots" for expected federal HCBS waiver, currently there are still vacancies in that category. The TennCare eligibility category of Web site does not offer a description or requirements for this category.
If slots are available in the category of HCBS, people like Byrd could be left to wonder by what may be left in the cold.
Home Services are a big budget problem for TennCare. Bredesen said the budget last September TennCare nursing home has grown by 53 percent since 2000, a total of 243 million U.S. dollars this year.
Gunderson became more focused.
"In 2000, it spent $ 18 million (private duty nursing)," he said. "In '07, we were spending 243 million U.S. dollars in the home health nursing private law, and if the trend had gone blank as it were, which have soared to about 496 million U.S. dollars in 2009.
"So they go from $ 18 million (in 2000) to a possible $ 500 million (in 2009) in which benefit only, and again, we're talking about a very small group of people. That's a lot of money to spend on a very small group of people. "
In fiscal year 2010 budget proposal TennCare, attention long term would have an increase of 12.4 percent, or approximately $ 950 million budget of 7.6 billion U.S. dollars of the proposed program.
No one is clear how the federal government reform might affect the health of state-provided Medicaid services, and each of the patients themselves representatives of TennCare are sometimes confused about details.
But with the recent announcement that CoverKids, Cover Tennessee program, will stop accepting new members November 30 despite the increase in federal matching funds, people all over are asking: What's next for TennCare?
"You almost can not believe you're in the United States, "Johnson said.
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