In March of this year, TJC was contacted by the single mother of two autistic children. She describes the situation best in her own words:
“My story should be an example that insured middle class working families that are supposed to have enough income to cover all medical expenses for their special children are also in need of assistance; my children deserve it.
I am lucky to be employed and able to provide the basic necessities for my family, but it is quite discouraging when even though you have private insurance, this one doesn’t cover specific tests/ therapies and doesn’t provide services to children with Autism after they turn 12 (like they by a miracle get cured) and the state insurance does. And you are told you are not eligible because of guidelines.”
TJC staff put their expertise to use, and realized that the kids qualified for TennCare under the complicated Medically Needy Spend Down category. After tracking bills which the mother had to pay on her own, we had her reapply at the end of June. Those bills numbered in the thousands of dollars, and the mother was rapidly eating into her savings to provide the best care available to her children.
The children were once again denied due to TennCare’s utilization of the Federally Facilitated Marketplace (FFM). The FFM was never designed to handle state Medicaid applications, and is unable to screen for the Medically Needy Spend Down category. TJC filed an eligibility appeal on the kids’ behalf.
In the end, a TJC Client Advocate and a TennCare attorney resolved the case three days before going to a hearing. The mother had this to say about her experience and the result: