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Judge Orders TennCare Eligibility Hearings

A federal judge has ordered state TennCare managers to hold hearings for Tennesseans who, because of application processing delays, have spent months waiting to find out if they qualify for taxpayer-finance health coverage.

U.S. District Court Judge Todd Campbell issued a preliminary injunction Tuesday — effective immediately — in a lawsuit against Tennessee’s Medicaid services agency that required the department to halt its refusal to provide hearings about delays in eligibility determinations within a certain number of days after one is requested. Those making the request have to prove that they have not learned the outcome of their application within 45 days if eligibility is based on income, while those seeking eligibility for a disability have to wait 90 days.

The lawsuit was also upgraded to class-action status.

“TennCare is committed to operationalizing the Judge’s Orders at this time,” TennCare spokesman John Goetz told TNReport Wednesday in an email.

The lawsuit was brought in July by the Southern Poverty Law Center, the National Health Law Program and the Tennessee Justice Center on behalf of several Tennesseans who felt their applications for assistance were not being heard in a timely enough manner, and that the state was not providing proper in-person assistance for applicants, instead sending them to the federal exchange.

The suit was filed shortly after the federal Centers for Medicare and Medicaid Services sent a letter to the state alleging it had failed to meet several of the requirements of the Affordable Care Act.

In his order, Campbell wrote that injuries suffered by the would-be TennCare enrollees “cannot be made whole by a retroactive award of money after the litigation process is complete.”

“The plaintiff class members are economically impoverished and, without TennCare benefits, have forgone or are forgoing vital medical treatments, services and prescriptions,” the judge added.

Tennessee Gov. Bill Haslam recently brushed off criticism that the state’s been dragging its feet signing up qualified applicants. Enrollment in 2014 is on record pace for the 20-year-old program’s history, the governor indicated.

One of TennCare’s attorneys argued that because of the issues the state has been having with getting its new eligibility system online, they had been given permission to send Medicaid applicants to the federal exchanges, and federal officials had failed to send necessary information to them about the plaintiffs that would help them process the applications faster.

Darin Gordon, the head of the agency, appeared before the General Assembly’s joint Fiscal Review Committee last week, and explained that Northrop Grumman — the company who won the bid to produce the system — was very much behind deadline, and the state had contracted with a third-party auditor to determine how much longer it would take for them to produce the necessary system.

However, Campbell wrote in his order that he was not persuaded that “the State can delegate its responsibilities under the Medicaid program to some other entity – whether that entity is a private party or the Federal Government.”

If a state decides to participate in Medicaid, “it is required to ensure that applications are adjudicated reasonably promptly and that hearings on delayed adjudications are held reasonably promptly,” Campbell continued in the injunction.

Additionally, according to the order, the federal government filed a “Statement of Interest” in the case, which said that TennCare “at all times retains the ultimate responsibility to ensure that a reasonably prompt decision is made on applications, including ones that have been submitted in the first instance to the federally facilitated Exchange in the State.”

Michele Johnson, executive director of the Tennessee Justice Center, said in a press release that her organization is “jubilant” that “vulnerable Tennesseans will now get the care upon which their lives and futures depend.”

Federal Court Grants Preliminary Injunction Against TennCare, Suit Upgraded

Press release from the Tennessee Justice Center; September 2, 2014:

NASHVILLE, Tenn. – A federal judge granted relief to residents across Tennessee today by ordering the state to provide hearings to residents whose Medicaid applications have been unreasonably delayed, according to a ruling in a case brought by a coalition of
civil rights groups.

The ruling by U.S. District Court Judge Todd Campbell granted a preliminary injunction sought by the groups and certified the
litigation as a class action lawsuit, meaning that it applies to all people in Tennessee who have waited months for a determination
on their applications for the program, TennCare. The Southern Poverty Law Center (SPLC), Tennessee Justice Center and the
National Health Law Program filed the lawsuit.

The court’s order takes immediate effect.

“This is a profound victory for all of Tennessee,” said Sara Zampierin, SPLC staff attorney. “The court’s ruling today will require TennCare to do their job and ensure that the people who have been stuck waiting for a decision for months will be able to finally receive the health care they deserve.”

The court rejected the state’s attempt to blame the federal government for its own failings, ruling instead that the state is responsible for its administration of the TennCare program, and noting that “[i]f a state decides to participate in the Medicaid
program, it is required to ensure that applications are adjudicated reasonably promptly.” The court further rejected the state’s claim that it has no “backlogs,” noting that the existence of this lawsuit proved that many people are suffering.

“We are jubilant that the vulnerable Tennesseans will now get the care upon which their lives and futures depend,” said Michele
Johnson, executive director of the Tennessee Justice Center. “We look forward to working with state officials to develop a process
that protects the health of Tennesseans and the infrastructure upon which we all rely.”

The court ordered that a fair hearing be provided to all class members who have proof of application and request such a hearing. The hearings will be held within 45 days, unless the person’s eligibility is based on a disability, in which case the State will have 90 days to conduct the hearing.

“We are pleased that Judge Campbell recognized this as a statewide problem,” said Elizabeth Edwards, Staff Attorney at the
National Health Law Program. “The law requires Medicaid applications to be processed promptly because low-income
individuals and people with disabilities often have a brutal need for health care that, without TennCare coverage, they will be unable to afford.”

A copy of the order can be viewed here: http://www.splcenter.org/get-informed/case-docket/Melissa-Wilson-et-al-v-Darin-Gordon-et-al.

TennCare Computer System’s Completion Date Still Unknown

Although he won’t speculate as to when the state’s new TennCare computer system will be completed, Darin Gordon, the program’s director, told members of the General Assembly he hopes a planned third-party audit will provide that answer.

Gordon gave testimony Tuesday to the Joint Fiscal Review Committee on the progress, or lack thereof, of the Northrop Grumman Corporation in developing the new “Tennessee Eligibility Determination System” for TennCare.

Tennessee has so far paid Northrop about $4.7 million of the $35.7 million it committed to the cybersecurity contractor in December of 2012, when they signed a three-year contract to develop the new system made necessary by the Affordable Care Act, Gordon said.

TEDS was supposed to go live in October 2013, and Northrop was last paid in January, Gordon added.

There are four “different tools” for the agency to ensure contractors comply with contract stipulations: penalties, liquidated damages, withholds and non-payment, in order of weakest to strongest. “We’re using the biggest tool that we have at this point to make sure that everybody is properly motivated to getting to where we want to be,” Gordon said.

Gordon said that Northrop, one of five firms to bid on the contract, made the lowest bid to produce the system. The next lowest was for $58 million, with the highest bid coming in at $109 million.

Wyoming, one of the other states to use Northrop to produce their system, is also “having challenges,” Gordon said.

Gordon told the committee that he had no idea as to when the system would be completed, because he’s “lost confidence in people’s ability to accurately predict” a timeline for completion.

Northrop is currently 99 percent done with its systems integration testing, the second phase of its five phases of implementation — but that doesn’t mean that phase is nearly done, Gordon said, because when issues with testing arise, developmental changes need to be made and the phase “can be at 99 percent for a longer period of time.”

The company is also about 80 percent complete with its third phase — user integration testing, but can’t start on the last two phases until the others are completed, Gordon explained.

“These are complex systems, there’s a lot of working in a very tight time-frame, and we want to make sure that what we do turn on, works,” Gordon said.

On Aug. 18, TennCare signed a no-bid contract with KPMG, an audit and advisory services firm, to run a 14-week audit of Northrop’s progress at a cost to the state of $1.2 million, Gordon told the committee. That report is expected to be ready sometime in late November or early December.

Following Gordon’s testimony, the committee also approved an extension of a contract with Policy Studies, Inc., the contractor who provides eligibility determination and processes application for the state’s children health insurance program. The contract, which is being extended through Dec. 2015 as a result of the delay in implementing TEDS. The contract extension is eligible for a 75 percent federal match.

The total cost to the state of the delay in getting the computer system on-line is not currently known, Gordon said.

The failure in bringing the new system online is one reason that TennCare is facing a lawsuit from the Southern Poverty Law Center, the National Health Law Program and the Tennessee Justice Center on behalf of several Tennesseans who have allegedly been denied coverage, though they claim eligibility.

“These system failures have serious impact on vulnerable Tennesseans and the health care infrastructure we all reply upon. It’s time for the state to spend less time blaming others and more time managing problems that have devastating consequences for our state,” said Michele Johnson, executive director for the TJC, in an e-mail.  Tennessee’s “lack” of a TennCare enrollment process “makes us unique in the nation,” she added.

The TJC filed the lawsuit because despite having met with TennCare officials since October of last year, “at some point it became clear that their willingness to problem-solve was not there,” and the Tennesseans they represent “couldn’t wait any longer,” Johnson told TNReport Wednesday.

Gordon was questioned by state Rep. Brenda Gilmore, a Nashville Democrat, about whether anything was being done to help hospitals cope with financial problems stemming from the inability to process emergency Medicaid applications because of the delay in TEDS implementation.

Gordon told Gilmore that because of the pending litigation the only information he could give was already included in his response to the federal Centers for Medicare & Medicaid Services, or in the briefs filed in the lawsuit.

However, the Gordon assured Gilmore that TennCare is in contact with the Tennessee Hospital Association “pretty much every week.”

Johnson told TNReport that she “thought it was interesting” the administration continued to say they couldn’t comment on anything related to the lawsuit because government agencies are required to “answer questions that the legislature has for their constituents.”

The next hearing in the federal case is scheduled for Friday.

Gordon noted to the committee that although TennCare has appeared before the legislature in the past, it wasn’t a result of computer system problems.

“Every state in the country all started from different starting points,” Gordon said. “Some had some modern technology already in place, and only had to adapt that technology to the new requirements. Other states, such as ourselves, had to start from scratch because our system was an old legacy system not capable of handling the changes that would be necessary to comply with the ACA.”

Additionally, the changes required by Obamacare have been “some of the most complicated” for the system since it began, Gordon explained.

Several other states — such as California’s backlog of hundreds of thousands of enrollees, or Oregon’s broken website and over-taxed Medicaid rolls — have had their own problems in developing a working system, Gordon said.

“These are complex systems, and are being implemented on a very quick runway, and so I think, if you look across the country, a lot of folks have had challenges with these,” Gordon said.

Haslam: TennCare Signing Up Lots of New Enrollees

The Volunteer State’s Medicaid program, TennCare, has been criticized by the Obama administration for not providing enough assistance to seekers of government aid under the Affordable Care Act.

But Gov. Bill Haslam this week defended the program, which enables lower-income residents to obtain taxpayer-financed health insurance and medical care. He said the number of Tennesseans finding their way on to TennCare’s rolls is on record pace.

“I think it’s worthy of note, we’ve signed up more people for TennCare this year than we ever have in the history of the program since it originated,” Haslam told reporters following an event to promote his new free-community-college program.

Actually, the governor’s estimates may be stretching it some. But 2014 does indeed appear so far to be tracking among years with the highest number of new sign-ups, John Goetz, a spokesman for the TennCare program, told TNReport in an email.

First-quarter TennCare signups this year were “the third highest in the 20-year history of the program,” wrote Goetz.

Dave Smith, Haslam’s spokesman, told TNReport by email that the governor had in fact “combined two stats: the number of new enrollees added in the first quarter was the highest in at least the last four years and the third highest in the 20-year history of the program.”

According to numbers pulled about three weeks ago, TennCare added 67,411 “new enrollees” to the program in the first quarter of 2014. The program enrolled 57,737 in the first quarter of 2013, 60,325 in the first quarter of 2012 and 62,065 in the first quarter of 2011.

TennCare was criticized by the federal Center for Medicare and Medicaid Services in late June for failing to provide aid and services required under the Affordable Care Act.

The Haslam administration was told by the Obama administration to quickly develop plans for getting its still-under-construction computer system online. In the meantime, the feds want Tennessee to establish a more adequate temporary enrollment process for hospitals to sign people up for government-funded insurance.

The feds claim that in wake of ACA implementation, Tennessee stopped providing personnel to help people sign up for TennCare, and instead began directing them to use the federal health care exchange at healthcare.gov — which has had problems of its own.

TennCare officials don’t see things in quite the same light.

The director of the state’s Medicaid program, Darin Gordon, sent Cindy Mann, federal director of Medicaid, a 16-page letter saying Tennessee “must respectfully disagree” with much of the Obama administration’s criticisms. Gordon’s letter asserted that in every county in Tennessee a TennCare agent is on duty and available for face-to-face meetings with potential aid-recipients to help them negotiate the complexities of state-and-federal Medicaid bureaucracy.

As for the state’s computer system, Gordon said that Northrop Grumman, the company who won the contract to produce the computer system, has missed several deadlines. Gordon added that while TennCare will continue to work toward “successful implementation” of the system, they would not “go live with a system that has not been adequately tested.”

The letter did include an “updated mitigation plan,” but Gordon also wrote in the letter that it was only an “interim solution pending completion” of a new computer enrollment system.

TennCare is also being sued by the Southern Poverty Law Center, the National Health Law Program and the Tennessee Justice Center on behalf of several Tennesseans who say they were illegally denied coverage.

SPLC, Others File Federal Lawsuit Against TN Over TennCare

Press release from the Southern Poverty Law Center; July 23, 2014:

Earlier this year, a high blood pressure episode put April Reynolds in the hospital. In fact, doctors told the mother of three that she could have died if she had waited any longer to seek medical treatment.

Reynolds put off going to the hospital because she didn’t have a way to pay for medical treatment. She had been trying to get coverage through Tennessee’s Medicaid program, but the state’s policies have deprived thousands of people like her the coverage they need even though they are eligible.

Now, Reynolds owes $20,000 in medical bills and needs monthly checkups. But she has been to the doctor only once since the episode because she’s afraid of accruing more debt.

Today, the SPLC filed a federal class action lawsuit against Tennessee for adopting policies that break its decades-old promise of health care to Reynolds and other vulnerable residents.

“Tennessee officials are sacrificing the health of the state’s most vulnerable citizens just to score political points,” said Sam Brooke, SPLC staff attorney. “They’re throwing a monkey wrench into their own Medicaid program so they can demonize the federal government. People in dire need of medical care are being sacrificed.”

The lawsuit was filed in the U.S. District Court for the Middle District of Tennessee in Nashville. The complaint, which was also brought by the Tennessee Justice Center and the National Health Law Program, comes on the heels of a scathing letter the Centers for Medicare and Medicaid Services sent to state officials for failing to meet six of seven critical success factors required by federal health care law – easily making Tennessee the worst state in the nation for fulfilling its Medicaid obligations.

According to the lawsuit, the state has violated federal law by discontinuing in-person help for applicants to its Medicaid program, TennCare. Instead, Tennessee forces applicants to apply for TennCare through the federal Health Insurance Marketplace website, which was not designed for this purpose, causing some residents – including those with serious medical conditions – to go needlessly without health care. To make matters worse, the state has stopped accepting TennCare applications in person.

Under federal law, an application for Medicaid must be processed in 45 days. The decisions Tennessee has made have resulted in many applicants – including all the plaintiffs in this case – being forced to wait more than two or three times the maximum period, with serious consequences.

“I have to worry every day about how my blood pressure is doing, which just escalates the problem,” Reynolds said.

The state also is arbitrarily terminating coverage for newborns after they are carried out the hospital door – a direct violation of regulations governing its state child health plan, “CoverKids.” Many newborns are now left without medical coverage during one of the most critical periods of their lives.

One plaintiff in the lawsuit is a baby identified as “S.G.,” who was born two months premature. He was born into CoverKids coverage, but Tennessee revoked it the moment he left the hospital. S.G. has not had coverage since leaving the hospital.

As a premature child, S.G. is at high risk of contracting the potentially fatal respiratory and airway virus RSV. He requires monthly shots – at $3,000 each – to prevent this illness. His parents can’t afford the treatment.

The changes that have deprived Tennesseans of coverage began in the fall of 2013 when the state ended in-person assistance for residents applying for TennCare, removing an important service that helped them navigate the application process. The state decided instead to make the federal Health Insurance Marketplace website, established under the Affordable Care Act, the only means for applying for TennCare, leaving many residents without coverage because the site cannot determine eligibility for individuals falling within certain categories.

As for Reynolds, she hopes the lawsuit will make the state live up to its promise to provide vulnerable residents with the health care they need.

“It would be such a burden off my shoulders,” she said. “It would make life a whole lot better. I think I’d live longer.”

THCC & TN Justice Center: ‘Health Care Freedom Act’ Posturing, Not Pragmatic

Press Release from the Tennessee Health Care Campaign & Tennessee Justice Center, March 7, 2011:

The personal responsibility provision of the Patient Protection and Affordable Care Act will be decided by the Supreme Court of the United States, not state legislatures

Nashville, TN – On March 7th, the Tennessee House of Representatives will take a vote on the “Tennessee Health Care Freedom Act”, a bill that essentially codifies objection to a single provision in the Patient Protection and Affordable Care Act.

Beth Uselton, Executive Director of the Tennessee Health Care Campaign, a non-partisan patient advocacy organization, says that this legislation is a distraction from the larger problems in our health care system. “This bill which seeks to reject aspects of the new health care law does nothing to help solve the problems it addresses. We still have hundreds of thousands of neighbors who lack affordable access to health care or have been denied coverage because of a pre-existing medical condition. The Patient Protection and Affordable Care Act will address both of these problems by banning pre-existing condition exclusions and providing tax credits to help people afford coverage. Attempting to pass state laws that reject provisions of the federal law are a distraction from the real problems Tennessee families are facing.”

Chris Coleman, an attorney with the Tennessee Justice Center, a non-profit public interest law firm explains that the state law would have no real effect on implementation of the Affordable Care Act. “Under the U.S. Constitution, laws passed by the U.S. Congress are the supreme law of the land, notwithstanding anything in the constitution or laws of any state. This means that the Affordable Care Act, much to the dismay of its critics, is the supreme law of the United States and preempts any contrary state law. If the legislature believes the ACA is unconstitutional, then it may try to convince the Attorney General to join one the several lawsuits challenging the ACA. What it cannot do is nullify a duly enacted federal law in Tennessee. As a legal matter, this is not even close.”

Uselton believes that the Affordable Care Act, not partisan politics, will ultimately prevail. “Those who seek to block implementation of the law or delay its benefits are playing politics with the lives and livelihoods of their own citizens. The new health care law is working for families across Tennessee who now have the peace of mind that their children can no longer be denied care or coverage because of a pre-existing condition. Patients with chronic conditions no longer have to worry that they will exhaust the coverage they’ve paid for or be dropped from their insurance because they got sick. In a new health care system where everyone participates and takes responsibility for their own health care, we can actually reduce costs, expand coverage and improve the quality of care. But we have to get past political posturing and start working together to implement real solutions to the problems facing Tennessee families.”