Is Tenncare And Medicaid The Same Thing


Cost And Coverage Of Medicaid Tennessee

A historic announcement regarding TennCare

TennCare insurance does not require a premium as long as you meet the income guidelines. You may have copayments for some services. If you have any other insurance, like Medicare or a private insurance plan, your other plans will pay before Medicaid. Medicaid can cover whatever your other plans didnt cover, but your other plans must pay first.

Who Can Get Obamacare Coverage

If youâre a legal resident of the United States, you can buy an Obamacare private health insurance plan through your state’s ACA health insurance exchange as long as youâre not enrolled in Medicare.

Subsidy eligibility: If your household income is in the subsidy-eligible range and you’re not eligible for Medicaid, Medicare, or an employer-sponsored plan that provides affordable, comprehensive coverage, you may qualify for a subsidy that helps pay part of your monthly health insurance premiums.

For several years, subsidy eligibility had an income cap equal to 400% of the federal poverty level. But that income cap was eliminated for 2021 and 2022, under the American Rescue Plan. The Build Back Better Act, under consideration in Congress in late 2021, would extend that provision through 2025.

Expanded Medicaid exception: Under the ACA, your household income has to be at least 100% of the poverty level in order to qualify for a premium subsidy. But subsidies are not available if you’re eligible for Medicaid, and in states that have expanded Medicaid under the ACA, Medicaid is available to people with income up to 138% of the poverty level. So the lower threshold for ACA subsidy eligibility is 139% of the poverty level in those states. As of 2021, Medicaid has been expanded in 38 states and DC, so the lower eligibility level for premium subsidy eligibility is 139% of the poverty level in the majority of the country.

Is Medicare The Same Thing As Medicaid

Although they sound similar, Medicare and Medicaid arent the same. The only similarity is that both government programs help cover health care costs for Americans.

Medicaid is designed for people that fall into a certain income bracket while Medicare is for people over the age of 65 or for those that have been on disability for two years, explains Grant Dodge, a broker at Health Benefits Associates Inc., in Reno, Nevada.

Medicaid doesnt have an age requirement, so adults of all ages and dependent children can enroll. In 2021, there were 75.4 million people covered with Medicaid. Medicaid plans are administered by the states but funded jointly by the state and federal government. Medicare is a federal program managed by the United States Centers for Medicare and Medicaid Services . The U.S. Social Security Administration handles Medicare enrollment and premium payments. It has an age requirement unless youve been on disability for 24 months or have specific medical conditions. Once you have both parts of Medicare from the federal government , you can sign up for additional coverage with private insurance carriers to fill in the gaps of Medicare, explains Dodge.

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How To Apply For Medicaid In Tennessee

If you are not automatically enrolled in Medicaid and need to apply, start by gathering the following information:

  • Any W2 forms or evidence of taxable income
  • Social security numbers and birthdates of those in your household
  • Any recent health insurance information
  • Official identity, citizenship information, or alien registration information
  • Employer information for anyone in the household who is employed
  • Any other income sources

After youve gathered as much information as you have, you can start your Tennessee Medicaid Application.

Former Governor Haslam Pursued Modified Expansion

Tennessee Medicaid: What Seniors Should Know About TennCare

In March 2013, Tennessees then-Governor, Bill Haslam unveiled his Tennessee Plan for Medicaid expansion. His proposal involved using federal Medicaid funding to purchase private coverage for up to 175,000 to 200,000 low-income Tennessee residents. It also called for copays for some enrollees, payment systems for providers that are based on outcomes rather than fee-for-service, and a clause that requires future renewal of Medicaid expansion to be approved by the legislature.

In November 2014, Haslam announced that his negotiations with the federal government were ongoing, and this was still the case in December, although Haslam stated he had verbal approval from the federal government for his plan. In January 2015, Governor Haslam called for a special session of the Tennessee legislature to address his Insure Tennessee plan.

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The Parts Of Medicare

Medicare is split into four distinct plans, with each providing different amounts and aspects of coverage.

Part A, also known as hospital insurance, pays for overnight hospitalization and most other fees that may be incurred during the course of treatment. Part A often comes into play when a patient requires surgery or must be admitted to the hospital following an accident or serious illness. Part A is provided at no extra cost to anyone who is eligible for Medicare.

Part B, also known as medical insurance, is an optional form of coverage that pays for routine outpatient treatment, such as x-rays, laboratory work, immunizations, and emergency care. Part B also provides coverage for medical equipment that patients might require, including wheelchairs, oxygen tanks, and prosthetics. Patients who enroll in Part B will be required to pay a separate monthly premium to receive benefits.

Part C is known as Medicare Advantage and is a combination of Parts A and B. It also has the flexibility to allow patients to enroll in Part D as well. Medicare Advantage has a lower monthly premium than other plans, but co-payments after receiving treatment are typically higher.

On the other side of the coin, is Medicaid.

Best Practices For Tenncare Dental Providers

Silver Diamine Fluoride

Silver Diamine Fluoride stops the progression of tooth decay and the application is quick and painless. It has been used in thousands of practices around the country since it was cleared for use as a desensitizer in 2014. TennCare reimburses for Silver Diamine Fluoride when CDT Code D1354 is used. Rather than sending the patient home with active disease, dental offices can now stop the disease progression with an SDF treatment. Please share the important benefits of this preventive measure with your patients. To learn more, please view DentQuests SDF toolkit at:

Dental Sealants

Dental sealants are safe and effective in preventing and arresting pit and fissure carious lesions in children and adolescents compared to the non-use of sealants or use of fluoride varnishes. And dental sealants minimize the progression of non-cavitated/initial occlusal carious lesions of the tooth that received a sealant. Please educate your patients on the importance of dental sealants. To learn more, please visit:

Community Water Fluoridation

Age 1 Dental Visit

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What Does Tenncare Cover

If you qualify, TennCare usually covers:

  • Medicare Part B premiums, deductibles, and coinsurance
  • Inpatient hospital services with limitations and deductibles
  • Outpatient hospital and rural health clinic services
  • Nursing home care
  • Long-term care alternatives, such as personal care services
  • X-ray and lab services
  • Medical supplies and equipment in limited situations
  • Physical therapy and

Tennessee Receives Cms Approval For Block Grant Medicaid Funding

Tennessee Republican introduces Medicaid expansion bill

In January 2021, just days before the end of President Trumps presidency, CMS announced that Tennessees Medicaid block grant waiver proposal had been approved. The waiver approval, which is valid for ten years , will allow Tennessee to be the first state in the nation that utilizes a block grant approach to federal Medicaid funding, although Puerto Rico has long used a block grant funding model for Medicaid, which has led to significant funding shortfalls in the territorys Medicaid program.

The Biden administration may make changes to the approved waiver, but they would have to go through a review process. Its noteworthy that law professor Nicholas Bagley pointed out in 2019 that Tennessees proposal was likely not legal under the existing rules for Medicaid and the constraints of what can and cant be changed with 1115 waivers.

In May 2019, Tennessee Governor Bill Lee signed H.B.1280 into law. The legislation directed the state to seek federal permission to convert the states current federal Medicaid matching funds into a block grant, indexed for inflation and population growth. The Trump administration had expressed willingness to consider such proposals, but Tennessee was the first state in the nation to enact legislation to get the ball rolling on it .

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Did Tennessee Expand Medicaid

Medicaid expansion in Tennessee Tennessee has not expanded Medicaid coverage as allowed under the Affordable Care Act, which means that there are an estimated 117,000 residents in the coverage gap ineligible for Medicaid and also ineligible for premium subsidies in the exchange.

Tennessee Medicaid Enrollment Numbers

During the first open enrollment period 83,591 people in Tennessee enrolled in Medicaid or CHIP through TennCare requested an additional $180 million from the state in late 2013 because of the rapidly increasing enrollment they were seeing soon after open enrollment began on the exchange.

As of August 2016, TennCare was covering 1.55 million people in Tennessee. A total of 1,628,196 people had coverage through Tennessees Medicaid and CHIP programs as of July 2016. That was a 31% increase since the end of 2013, despite the fact that the state had not expanded Medicaid. This is known as the woodwork effect, as people who were already eligible for Medicaid under the existing guidelines come out of the woodwork thanks to the outreach and enrollment efforts under the ACA.

Enrollment in Tennessees Medicaid/CHIP coverage fell sharply since 2016 amid the states efforts to purge children from the coverage rolls . In February 2019, total enrollment stood at just over 1.3 million people.

As of late-2021, Tennessee Medicaid and CHIP enrollment was 1,623,017.

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How Long Does It Take To Get A Tenncare Release

Responses for Release Requests submitted via email and fax have significantly shorter turnaround times: releases for decedents who did not receive TennCare benefits will be emailed to the requester within one business day, while responses for decedents who did receive TennCare benefits will be emailed within three

Tennessee May Get More Federal Medicaid Dollars Without Spending Any New State Money

Tennessee Medicaid: What Seniors Should Know About TennCare

If TennCare spends less than its new federal cap, the state could get up to 55% of the difference as shared savings. The agreement lets Tennessee use existing state spending on other health-related programs to match this money, which is not currently allowed. However, savings rolled over from the prior waiver do not count. This new source of federal funding would free up as much as 65% of the state dollars currently spent on the programs listed below. Only state spending on these programs would be eligible for a shared savings match, and any changes to this list would require federal approval.

  • Charitable clinics funded by the Department of Healths primary care safety net
  • The Department of Mental Health and Substance Abuse Services behavioral health safety net
  • Safety net services funded by the Department of Intellectual and Developmental Disabilities
  • K-12 nurses, psychologists, social workers, and at-risk student services funded through the Department of Education
  • CoverRx prescription drug assistance program for low-income Tennesseans

The level of shared savings available to Tennessee will depend on its performance on quality measures. Tennessee could access 45% so long as it maintains its performance on a to-be-determined set of 10 quality measures. If the state shows improvement on the measures, it could earn up to 55% of shared savings. It is unclear if the process of choosing the measures will play out in public.

Figure 2

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What Is The Income Range For Beneficiaries Who Are Dual Eligibles

Generally, beneficiaries earning less than 135 percent of the federal poverty level are eligible for the MSP if they also have limited savings . This equates to $17,226 annually for single beneficiaries and $23,274 for married couples. Beneficiaries qualify for full Medicaid benefits if their incomes and assets are even lower .

Many seniors who live in nursing homes are dual eligible: they qualify for Medicare based on their age, and Medicaid because of their financial circumstances. It is also common for Medicare beneficiaries who are under 65 and live on Social Security Disability Insurance to receive Medicaid benefits.

The New Shared Savings Provisions Add To The States Existing Financial Incentive To Reduce Tenncare Spending

The shared savings approach increases the value to the state budget from spending less on TennCare. In FY 2019, TennCare took up about 21% of all state spending, so there is already a strong incentive to find efficiencies in the program. Under the new waiver, however, any reduction in TennCare spending could free up about twice as much money in the state budget. Currently, reducing total TennCare spending by $3 saves roughly $1 for the state and $2 for the federal government. Going forward, however, the state would also keep about half of the federal savings which could free up state dollars for other purposes .

The maintenance of effort requirement does limit Tennessees ability to reduce its Medicaid spending. TennCare could tap new and existing flexibilities to produce savings within the funding cap that could potentially affect things like utilization or payment models. However, any changes that explicitly reduce eligibility or benefits below December 2020 levels would require federal approval and trigger an adjustment to the states aggregate cap. There would be no additional financial incentive to reducing enrollment since the cap falls when enrollment falls by more than 1% below 2019.

Figure 5

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Is Tenncare The Same As Medicaid

TennCare is the state of Tennessees Medicaid program. It provides healthcare to mostly low-income pregnant women, parents or caretakers of a minor child, children and individuals who are elderly or have a disability. To get Medicaid, you must meet the income and resource limits. You can apply anytime for TennCare.

Who Is Eligible For Medicare And Medicaid

Tennessee’s Medicaid “Block Grant” Explained

In general, people whove reached age 65 are eligible for Medicare. People younger than 65 may be eligible for Medicare if they have end-stage kidney disease or ALS . People under 65 whove received Social Security or Rail Road Board disability benefits for longer than two years may also be able to enroll early in Medicare.

Medicaid eligibility rules vary by state. In general, Medicaid is available to families with few assets besides a house and car, those with certain disabilities and those with low-income. Medicare recipients may also be eligible for Medicaid. You can use the map tool at for details about eligibility, programs and quality of services in your state.

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How Do I Know If I Should Be Dual Eligible

Beneficiaries can find out if theyre eligible for Medicaid by contacting their Medicaid office. An Internet search for Medicaid offices in a beneficiarys state should provide the number to call but beneficiaries should make sure they are contacting a government office before sharing any personal information.

The Centers for Medicare and Medicaid Services also maintains a list of state agencies that oversee Medicaid. Beneficiaries can see if they already have Medicaid by contacting 1-800-MEDICARE and asking whether they receive Extra Help with their prescription drug costs .

Having Both Medicare And Medicaid

If you meet the income eligibility requirements for TennCare and are also over the age of 65 or diagnosed with either ALS or ESRD, you can have both Medicare and Medicaid. This means that you can qualify for a dual-eligible Medicare Advantage plan and make the most of your available benefits. To get help selecting a dual eligible plan, contact our partners at Medicare Plan Finder. They can send a licensed agent to your home to help you select a plan from the hundreds of options available in Tennessee, with no bias and no purchase required.

*This post was originally published on December 5, 2013, by Ashley McNurlan, and updated on November 21, 2018, by Anastasia Iliou.

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Can I Select An Insurance Plan For My Medicare And Medicaid Benefits

If you are dual eligible, you are can enroll in a dual eligible special needs plan that covers both Medicare and Medicaid benefits. These plans may also pay for expenses that Medicare and Medicaid dont over individually, including over-the-counter items, hearing aids, and vision or dental care.

Beneficiaries who are dual eligible can change between Original Medicare and Medicare Advantage or switch Part D plans at each quarter.

Read more about the Medicaid benefits available to Medicare enrollees.

Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including at Sachs Policy Group, where he worked with insurer, hospital and technology clients.

Tenncare Can Limit Coverage Of Prescription Drugs A Common Practice For Private Insurers And Medicare But Never Before Allowed In Medicaid

Tennessee Medicaid: What Seniors Should Know About TennCare

Tennessee is the first state allowed to use a restricted drug formulary for Medicaid. For adult enrollees, TennCare can choose not to cover some prescription medications without losing mandated discounts from the drug industry. However, the state would have to allow exceptions when a non-covered drug is deemed medically necessary a process that has not yet been established. Exemptions are also carved out for drugs to treat HIV/AIDS and opioid use disorder. While federal regulators have never before approved a restrictive formulary in Medicaid, Tennessee and many other states do require prior authorization for drugs that are not on their preferred lists.

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