Tennessee Pharmacists Association

TennCare has provided the following information about the transition plan for TennCare enrollees regarding their medical coverage under the TennCare Managed Care Organization (MCO) program. These changes do not affect enrollees’ TennCare Pharmacy Program benefit coverage, which is carved out from the MCOs and is managed by the TennCare Bureau through its contract with Magellan.

From the Bureau of TennCare:

Attention TennCare Providers

As you may know, TennCare is in the process of making changes in our service delivery system across the state. Beginning January 1, 2015, AmeriGroup, BlueCare and UnitedHealthcare will all be available statewide. TennCare has been working with each health plan on a transition plan in order for each health plan to have a similar amount of members assigned to them.

As a result of this transition some TennCare members will be transitioned to a new health plan. Not all members will change plans. These members will begin receiving letters on November 15, 2014, notifying them they will have a new health plan effective January 1, 2015. As a result of these letters you may receive calls from your patients asking about their network coverage.

As a provider you are an integral part of TennCare’s mission of providing high quality health care for our members. We have provided below some of the common questions or concerns regarding this transition. We hope this will be helpful in answering any questions you may receive from patients. You may also direct your TennCare patients to call Tennessee Health Connection at 1-855-259-0701 with questions. As a provider, if you have questions or concerns you may contact TennCare Provider Services at 1-800-852-2683.

Thank you for your ongoing commitment to service our members.

What changes are taking place?
TennCare is transitioning from two health plans in each grand region of the state to three health plans statewide. Since January 1, 2009, UnitedHealthcare and BlueCare have operated in East and West Tennessee and UnitedHealthcare and AmeriGroup have operated in Middle Tennessee. Starting January 1, 2015, UnitedHealthcare, BlueCare and AmeriGroup will be operating statewide. This will offer more options to our members. Since three instead of two health plans will be available to members, some members will transition to a new health plan to ensure even distribution of enrollment.

What is the timeline?

November 14, 2014:
Notices will be sent to transitioning members informing them of their new health plan assignments.

December 31, 2014:
Members who were sent a notice have until this date to request to stay with their current health plan. There is information on how to do that included with their notice. Members will continue to be enrolled in their current health plan until December 31, 2014. Members can only transition to their new plan or request to stay with their current plan, they cannot request to move to another plan. They will be able to choose any plan during their annual open enrollment period.

January 1, 2015:
Members who were sent notices and did not request to stay with their current health plan will transition to their new health plan. This may mean they will have to see new doctors and health care providers if their new health plan does not contract with their current providers. Prior to this transition, members will receive welcome letters, member handbooks, provider directories and membership ID cards from their new health plan.

February 14, 2015:
Members who transitioned to a new health plan have until this date to request to change back to their previous health plan. There is information on how to request to change back to their previous health plan included with their notice.

What if a member wants to change health plans after February 14, 2015?
Members can request to change health plans during their annual open enrollment period. Members in West Tennessee can change their health plan during the month of March. Members in Middle Tennessee can change their health plan during the month of May. Members in East Tennessee can change their health plan during the month of July. Information about open enrollment can be found at: http://www.tn.gov/tenncare/mem-plan.shtml

Do members need to “re-apply” for TennCare?
No. A member’s eligibility is not changing. If a member does nothing after receiving the notice he or she will remain on the TennCare program but will be assigned a new health plan.

Will there be any changes to the services TennCare covers? 
No. TennCare covered services will remain the same.

Will TennCareSelect continue to operate as a TennCare MCO?
During and after the transition, TennCareSelect (which is operated by Volunteer State Health Plan) will continue to serve a small population of individuals including children in state custody and children receiving SSI.

What will happen with my patients’ prior authorizations?
To ensure continuity of ongoing treatment and services, the member’s current health plan will transfer information concerning prior authorized services to the member’s new health plan. Patients can call their new health plan if they have questions, or need help. For care that has not started yet, you will need to contact the patient’s new health plan to obtain any necessary authorizations for service. The new health plans will be responsible for making all new prior authorizations after January 1, 2015.

Will the transition disrupt my patients’ existing course of treatment?
Old language: No. The state’s new contract with the health plans has provisions to assure a smooth transition, particularly for TennCare enrollees currently receiving a course of treatment. For example, a pregnant woman in her second or third trimester will be able to keep her current healthcare provider through her delivery and postpartum care – even if the provider does not participate in her new health plan.

The new health plan will be responsible for coordinating care for all enrollees, with a particular focus on those undergoing active treatment for chronic or acute medical or behavioral health conditions as well as CHOICES members. Continuation of services for up to 90 days or until the member may be reasonably transferred to an in-network provider without disruption is required.

What will happen with my patients’ prescription refills?
These changes will not have any impact on the TennCare pharmacy benefit. Members will be able to access pharmacy services in the same way that they do today during the transition and afterward.

What if I feel that the rates of the new health plan in my region are not high enough?
The Bureau of TennCare does not establish rates, nor does it get involved in rate negotiations between the health plans and private providers. Rather, the Bureau’s role is limited to ensuring that the health plans have an adequate number of providers within their respective networks. Accordingly, the Bureau refers all questions regarding provider rates directly to the health plans.

What if the new health plan in my region will not contract with me?
The Bureau of TennCare’s overriding concern is that the health plans meet their contractual requirements for an adequate network of providers. The health plans retain flexibility as to the specific providers with which they may contract. Consequently, the Bureau refers all questions regarding provider contracting directly to the health plans.