CINDY SANDERS

"It's been a busy nine months," stated … or rather understated … Commissioner Dave Goetz of the Tennessee Department of Finance and Administration.

In less than a calendar year, Goetz and his team have rolled out all four of the programs for which they have oversight under the umbrella of Cover Tennessee, the state's initiative to provide more children, uninsured workers and those with preexisting conditions access to affordable health coverage.

The fifth program, ProjectDiabetes, is also up and running, but comes under the purview of the Department of Health.

CoverKids, which is part of the federal State Children's Health Insurance Program (SCHIP), officially launched in March. Earlier that month, Gov. Phil Bredesen celebrated the kick-off of CoverTN, an affordable and portable insurance initiative for working Tennesseans. AccessTN, the program for seriously ill adults who have been denied commercial insurance, rolled out in mid-February; and CoverRx, designed to make medications more affordable, launched on Jan. 1.

The initiative's Web site has detailed information regarding each of the programs. Particularly helpful to providers and patients seeking information is the "FAQ" section (www.covertn.gov/faq.html), which outlines eligibility requirements, scope of services and the application process.

With any of the Cover Tennessee programs where income is a qualifying factor, the threshold is 250 percent of the federal poverty level (FPL).

"Basically, the average family size in Tennessee is three so that would be $41,000 a year (household income)," noted Goetz.

BlueCross BlueShield of Tennessee oversees the three main insurance plans and ExpressScripts is the pharmacy benefits manager on CoverRx.

"We didn't really anticipate it happening this way," said Goetz. "We had a very vigorous procurement process. For CoverTN … BlueCross won. For CoverKids and AccessTN, BlueCross was the only bidder."

He added, "You've got to give BlueCross credit, they stepped up on this and provided a really good plan."

CoverKids
Tennessee's SCHIP program, CoverKids, is modeled after the state employee plan but with add-ons for well child visits and immunizations, Goetz said.

"It basically tries to follow the American Academy of Pediatrics guidelines," he explained. "We're seriously looking at adding dental and vision pretty quickly," he continued.

Goetz said there is a strong focus on outreach as the state attempts to get as many children covered as possible. The last census numbers indicated 125,000 uninsured children in Tennessee.

Typically, when states begin promotion campaigns to enroll kids in SCHIP programming, children who qualify for Medicaid are uncovered. In Tennessee, children will be slotted into either CoverKids or TennCare depending on their income qualifications.
"In other states, what they've found is about 41 percent of the kids are Medicaid-eligible," he noted, adding that the program is too new for Tennessee to have any hard statistics yet.

For families whose children qualify for CoverKids, there is no premium. However, there is a buy-in option for families with uninsured children above 250 percent FPL.

Pregnant women who meet the income requirements can enroll in CoverKids to receive maternity benefits and prenatal care. If a woman is already in CoverTN when she becomes pregnant, she is automatically enrolled in CoverKids. There is, however, only one presumptive eligibility for pregnancy per 18-month period.

CoverTN
The state's solution for small employers, CoverTN offers businesses the option to split premiums three ways between the employer, employee and state. As of early April, 10,000 businesses had already gone online to prequalify for the program and about 34,000 full applications were in the enrollment process with BlueCross, the plan administrator.

Goetz said an individual's actual premium is based on three criteria: age, weight and tobacco use.

For a healthy 41-year old, he said, the cost would total $150 a month, which amounts to $50 monthly out-of-pocket for the employee.
"If you're a healthy 20-year old, it's $34. If you're an unhealthy 60-year old, it's going to be $99 (a month)," he said of the range.
Unlike Massachusetts, which is the model for many state plans, CoverTN does not have a large deductible. Goetz said when there is a high deductible in place, prevention and primary care suffers and emergency rooms overflow.

"The relationship with the primary care provider has been broken," he said. "We're trying to reknit that relationship with CoverTN. That's why there is no deductible. People are encouraged to go see their doctor. They can get conditions checked and found and even maintained."

However, in order to keep the plan affordable, he added, "There is an overall limit on the total payout of $25,000 per individual per year."
The coverage is also portable.

"If you change jobs and the employer is enrolled, there's no break in coverage. If you have a couple of months (without work), you can pay the two-thirds (premium cost), and there's no break in coverage. If you get a new job, and the employer won't get on the program, you can pay the two-thirds, and there's no break in coverage," Goetz enumerated.

The bottom line, he said, is that the state wants to encourage people to keep some level of coverage over time.

"It's on average with a cell phone bill so when people are sitting down at the end of the month, this stays in the mix," he said of the plan's affordability.

AccessTN
There are three ways to qualify for this program. The first is a letter from a doctor affirming you have one of 55 different medical conditions — such as HIV/AIDS, congestive heart failure, or most forms of cancer — which automatically qualifies you for the plan (full list available at www.covertn.gov/faq.html). The other options are to present two declination letters from underwriters proving you have tried and failed to purchase coverage in the commercial marketplace or to pay a fee of $75 and go through the state's underwriting process. While there is a six-month, preexisting condition waiting period, Goetz said plan participants would be able to receive pharmaceuticals from the first day of enrollment.

Goetz added there are a limited number of slots in the AccessTN program.

"We had reserved three-quarters of the slots … or 4,500 out of 6,000 … for those disenrolled from TennCare," he explained, adding there was a 60-day window that began March 1 to take advantage of the reserved spaces. "At the end of that time, if we've not filled all the slots, they convert to general slots."

Because this program is for a high-risk pool, monthly premiums are significantly more expensive than the CoverTN plan.

However, Goetz said, "The state already takes on about 40 percent of the premium for everybody. For lower income people, they can apply for premium assistance."
He estimated that of those processed into the risk pool to date, approximately 75 percent are receiving some financial assistance.
"We're one of the few states that does any premium assistance at all," he noted.

Cover Rx
"Cover Rx is a direct outgrowth from what we learned from the disenrolled TennCare population," explained Goetz.

Under the Safety Net provisions of the past year, the state has continued to provide an insulin benefit to diabetics and supplied antipsychotic drugs to those diagnosed with serious and persistent mental illness (SPMI). The state auto-enrolled all the SPMI population in their databank into CoverRx so these patients could continue their medications without interruption.

"In just a few weeks, the program went from 0 to 21,000," Goetz said. "Utilization was much higher than expected," he continued, noting that his office had to temporarily halt enrollment when the program so rapidly exceeded the budget allocation to allow state officials to assess the situation.

However, the state reopened enrollment on April 30 for the more than 3,500 already on the waiting list as well as new applicants.
The program is typically open to Tennessee residents at or below 250 percent FPL. Because it isn't an insurance plan, there are no premiums. Instead, the program is run with sliding scale co-pays depending upon household income.


May 2007