TJC Story Blog
January 2020
These are the stories of the plaintiff’s of the A.M.C. et al. vs. Smith, a class action lawsuit TJC filed in the spring of 2020. The lawsuit addresses systematic issues with TennCare’s eligibility process. Learning what our clients faced, it became apparent that we must take action to break down the barriers they faced trying to receive the care they needed, particularly in light of the pandemic. Read more about the class action “AMC” lawsuit here.
SFA
SFA is now two years old and lives in Campbell County, Tennessee. She was born with spina bifida and requires surgeries and constant monitoring to treat her condition and prevent serious medical complications including death. SFA lost TennCare without any notice and was turned away from a necessary MRI appointment because of her loss in coverage. Even when SFA’s mom called TennCare to explain the situation and file an appeal, SFA’s coverage was not reinstated for over 3 months.
Barnes
Ms. Barnes is 74 years old and worked for many years as a hotel housekeeper until she developed osteoarthritis. She has received SSI since 1994 and is eligible for TennCare as an SSI recipient. Abruptly in the summer of 2019, TennCare told her that she might lose coverage even though she was still receiving SSI and still eligible for TennCare. Last October Ms. Barnes suffered a broken ankle and needed to be hospitalized for several days. While arranging for physical therapy, she learned that she had been terminated from TennCare even though she was still eligible. While Ms. Barnes was recuperating from her accident her daughter had to assist in getting her back on TennCare. Even though TennCare has access to SSA records and should know that Ms. Barnes receives SSI, her daughter has had to repeatedly submit information and appeal to TennCare showing that she is eligible.
AMC
AMC is now four years old and lives in Cumberland City, Tennessee. AMC has epilepsy which results in seizures. AMC has lost TennCare twice without any notice even while other members of her family remained on TennCare. Even when AMC’s mother explained the situation and the urgency of AMC’s need for coverage, TennCare would not reinstate her coverage and failed to resolve AMC’s case. AMC’s coverage was finally reinstated after TJC contacted TennCare directly. Unfortunately, TennCare still left a gap in coverage. AMC’s mom filed another appeal and was able to get the gap covered. During the months AMC lost coverage she was rushed to the hospital twice and incurred expensive medical bills that her family could not afford. After AMC’s coverage was finally corrected, AMC’s mother filed another appeal to get the unpaid medical bills covered. For over five months AMC’s mother worked to get those bills covered by TennCare.
Carlissa Caudill
Ms. Caudill is now 57 years old and lives in Russellville, Tennessee. Ms. Caudill sustained serious neurological and orthopedic injuries from multiple accidents in her life. As a result, she qualifies for and receives SSI benefits. Through Social Security and TennCare should be in consistent communication and all SSI recipients should automatically receive TennCare, Ms. Caudill received a termination notice from TennCare. Ms. Caudill tried to explain her need for coverage to TennCare and filed an appeal but was told repeatedly that she was not eligible. Ms. Caudill’s coverage was finally reinstated after TJC contacted TennCare directly. Through Ms. Caudill was supposed to receive a continuation of benefits, her doctors repeatedly told her she didn’t have coverage when she tried to book an appointment. When she was finally reinstated, Ms. Caudill visited her doctor and learned she had cancerous skin cells. She has recently learned she may have a malignant cells in her lungs and is worried that she could lose her health insurance at anytime during this difficult period.
Cleveland
Ms. Cleveland is 61 years old and for several years qualified for TennCare because she received SSI benefits. In July 2019 she started receiving Social Security Widow’s benefits after her husband passed away, and this made her income too high to qualify for SSI anymore. TennCare promptly informed her that they would be terminating her coverage because they’d been notified by SSA that she no longer receives SSI. TennCare also had access to SSA records showing Ms. Cleveland was eligible for TennCare as a Social Security Widow, but they did not check her for eligibility in this category before telling her she was going to be terminated. She lost her coverage and had to borrow money for medical expenses while she worked to appeal the termination, and she did not get re-enrolled until reaching out to TJC for help in March 2020.
Hill
Mr. Hill is a 47 year old man who has cognitive impairments and needs assistance with activities of daily living, and he has received Medicaid benefits for his entire life. He has remained eligible for TennCare, but in February of 2019 he abruptly received a notice saying that TennCare was going to stop paying for his prescriptions. His sister came to his aid and filed multiple appeals with TennCare that went unanswered. In September, he also received notice that he was losing his Medicare Savings Plan because TennCare mistakenly thought he did not have Medicare. By the time TJC filed this lawsuit in March, it was still not clear what the status of Mr. Hill’s coverage was.
JSK
JSK learned that his family had lost TennCare in September 2019 while picking up a prescription at the pharmacy. The month before he’d gotten a letter saying that his family needed to renew their coverage, but they received the letter after the deadline to renew. He’d immediately called TennCare and was told that they could renew coverage over the phone with no problems. They contacted TJC for help and learned that they had lost coverage because TennCare was slow to process their renewal. TJC had to contact TennCare several times over a period of months before the family’s renewal was process and coverage was restored.
EIL
EIL is now 1 year old and lives in Nashville, Tennessee. When EIL was born his mom was on TennCare and so he should automatically get TennCare when his birth is reported. TennCare covered all the bills incurred during his birth but then gave EIL the wrong start date to his coverage creating a gap. EIL’s mom learned about this almost a year later when a doctor would not see EIL because there were outstanding bills incurred during the gap of coverage. EIL’s mom also learned that TennCare was sending notices to the wrong address. When EIL’s mom explained the situation and tried to fix the problem through an appeal, TennCare would not let her have a hearing because they said she did not file an appeal on time. After EIL’s coverage was corrected, EIL’s mom had to file another appeal to get the bill incurred during the gap covered.
Monroe
Mr. Monroe is a 69 year old man who has a hearing impairment and a condition that limits the use of his hands. He learned last September that his Medicare Savings Plan was to be terminated because he did not respond to a letter he never received. Mr. Monroe and his TJC advocate repeatedly expressed his need for accommodations to TennCare, because he struggled to provide information by mail or over the phone. TJC submitted evidence to TennCare that Mr. Monroe is eligible for TennCare Medicaid, but TennCare denied him coverage without considering this information and still had not approved his coverage when TJC filed this lawsuit in March.
Rebeaud
Ms. Rebeaud has been eligible for TennCare since she began treatment for breast cancer in 2013. Last July, her coverage was suddenly terminated even though she had submitted all required documentation on time. She experienced intense anxiety and depression during the weeks that she did not have coverage for her cancer treatment, and she reapplied for TennCare. After her new application was approved, TJC helped her to get the period that she was without TennCare covered retroactively.
TJT
TJT and his wife are parents of three children. Their issues with TennCare began when they found out that their son had lost coverage while they were picking up a prescription for him. They called and were able to get him re-enrolled, but a few months later they received a notice saying three members of the family were going to lose coverage. They called TennCare and were told that the remaining two members of the family had active coverage, but a few months later learned that one of them had been without coverage for almost a year. He had been “purged” due to a system error and no notice was sent about his termination. After several months of back and forth with TennCare they contacted TJC, and although they were able to re-enroll in TennCare their coverage started on incorrect dates and left a large gap in coverage.
Kerry Vaughn
Ms. Vaughn is now 50 years old and lives in Nashville, Tennessee. Ms. Vaughn was born with cerebral palsy and as a result, she qualifies for and received disabled adult child (DAC) social security benefits. Ms. Vaughn relies on her TennCare coverage to get to doctors appointments and for medical supplies to manage her disorder. Though Ms. Vaughn is eligible for TennCare, TennCare has attempted to terminate Ms. Vaughn twice. Each time Ms. Vaughn filed an appeal and explained how she qualifies for TennCare. In her most recent appeal, it took over nine months for TennCare to realize their mistake and reinstate her coverage.
Johnny Walker
Mr. Walker is now 52 years old and lives in Franklin County, Tennessee. Mr. Walker has a disabling cognitive impairment that includes short term memory loss after he was injured in a train accident when he was 17. As a result, he qualifies for and receives SSI benefits. Through Social Security and TennCare should be in consistent communication and all SSI recipients should automatically receive TennCare, Mr. Walker lost his TennCare coverage. Mr. Walker had difficulty navigating the process with TennCare and sought help from family members and friends who connected him with TJC. For many months Mr. Walker had to make the decision to go without his medication or to pay out of pocket for the medication he could not afford without buying less groceries. Ms. Walker’s coverage was finally reinstated after TJC contacted TennCare directly.
