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Hurdles To Medical Care

The State will cut $1.2 billion of federal funds from health services from TennCare in the next few years. Click here to look more closely at the state budget. The cuts are a conscious decision to save money by denying care to people with severe health problems. There are now three major hurdles to care:

Medical Necessity

TennCare covers only what is “medically necessary.” So, the definition of this term is vitally important. In Spring 2004, the Tennessee Legislature changed the TennCare definition of medical necessity for adults and children. TennCare’s new definition only allows people on TennCare to get the cheapest treatment that is considered “adequate” by TennCare bureaucrats. This sets up a two-tier system of health care. People with private insurance get the treatment their doctor thinks they need. TennCare enrollees can’t. The denial of needed care will cost us all in downstream cost.

2+3 Prescription Limit

 TennCare has imposed prescription limits on all enrollees except children and adults in long-term care facilities or waivers.

All other adults on TennCare are limited to 5 prescriptions per month. Of those 5, only 2 can be brand name. The other 3 must be generic. People who need more will have to buy medicine or go without if they can’t afford it.

The Biggest Hurdle – Losing Coverage

Hundreds of thousands of people on TennCare have lost coverage or face being cut from TennCare. Among those being cut are:

• As many as 1,500 nursing home residents
• 30,000 severely and persistently mentally ill adults
• 67,000 uninsurable adults
• 38,000 elderly and disabled Medicare enrollees

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