Nearly 3,000 rejected for TennCare nursing home coverage under new point system

In an effort to curtail costs while meeting the health needs of aging baby boomers, TennCare officials have put in place new rules that create a higher hurdle for families to qualify for nursing home coverage. Since then, The Tennessean reports that nearly 3,000 people who probably would have been judged to need nursing home care in early 2012 are instead getting only limited home visits.

The new guidelines are under fire from state legislators and advocates for the elderly and disabled. They question why TennCare launched the point system by emergency rule — a move that limited the degree of public input. Only one hearing, attended by 36 people, was held, just two months before the rules took effect in July 2012.

“I would contend that it was really without any real legislative or stakeholder input at that point in time,” said Jesse Samples, executive director of the Tennessee Health Care Association, which represents nursing homes.

Now that the system is in place, however, the state intends to keep it. Patti Killingsworth, TennCare’s chief of long-term care, told a state Senate committee in December that the agency has no plans to abandon the point system, saying there could be a “significant financial impact if standards were relaxed.”

The agency’s goal was to save $47 million in fiscal 2013 by diverting 20 percent to 25 percent of nursing home applicants to home or community-based care, Killingsworth said. The state is just under that range with a 19.6 percent diversion rate.

…Tennessee, which previously allowed people to qualify for Medicaid-funded nursing home care with only one deficiency of daily living, such as not being able to walk, now stipulates that applicants score nine points on a 26-point evaluation administered by TennCare nurses.

Someone could be incontinent, have problems walking, be unable to manage their medicines and still not score nine points.

…After complaints from families and nursing homes, a state Senate committee asked TennCare officials to explain the system at a hearing in December.

Since that hearing, legislators have introduced two bills — one that would require the director of the Tennessee Commission on Aging and Disability to have input on decision making about the Choices program, and another that would require an accounting of the money that Medicaid-contracted insurers make under the program.

TennCare provides incentives to these contractors, known as managed-care organizations, to lower overall health spending.

TennCare also has taken some actions since the hearing. In a follow-up letter to Sen. Joey Hensley, R-Hohenwald, Killingsworth said the agency may consider more information from applicants who seek a “safety determination,” an override that has allowed more than 750 people to qualify for nursing home care when they did not score nine points.

Killingsworth said TennCare will give nursing homes a 10-day window to submit additional information when an application has been denied, and it may expand some definitions — for instance, including diagnoses other than dementia when evaluating an applicant’s behavior.