The TennCare program operates under a Section 1115 waiver from the Centers for Medicare and Medicaid Services (CMS) in the United States Department of Health and Human Services. It is a demonstration program. The principle being demonstrated by TennCare is that a state can organize its Medicaid program under a managed care model and generate sufficient savings to extend coverage to additional populations who would not otherwise be Medicaid eligible, without compromising quality of care.

TennCare is one of the oldest Medicaid managed care programs in the country, having begun on January 1, 1994. It is the only program in the nation to enroll the entire state Medicaid population in managed care.

Medicaid waiver programs are time-limited. The first TennCare waiver ended on June 30, 2002. The waiver under which TennCare is now operating is called “TennCare II.” It began on July 1, 2002, and has been extended through June 30, 2010. In the summer of 2009, the state will begin preparing the next extension request.

TennCare services are offered through managed care entities. Medical and behavioral services are covered by “at risk” Managed Care Organizations in each region of the state. Enrollees have their choice of MCOs serving the areas in which they live, except that some enrollees are assigned to TennCare Select. TennCare Select is a managed care plan for certain populations such as children in state custody and enrollees who may be living temporarily out-of-state. In addition to the MCOs, there is a Pharmacy Benefits Manager for coverage of prescription drugs and a Dental Benefits Manager for provision of dental services to children under age 21. Coordination of care is the responsibility of the enrollee’s primary care provider in his or her MCO.

Long-term care services are provided in Nursing Facilities (NFs) and Intermediate Care Facilities for persons with Mental Retardation (ICFs/MR), as well as under Home and Community Based Services waivers for persons who would otherwise require care in a NF or ICF/MR. These services have historically been “carved out” of TennCare and paid for by the state through a fee-for-service arrangement. However, the state is making plans to bring long-term care services for persons who are elderly and disabled into the managed care program, beginning in the summer of 2009.

The Bureau of TennCare within the Tennessee Department of Finance and Administration is the state agency charged with responsibility for administering the TennCare program. In addition to overseeing the contracts with the managed care entities and overseeing the long-term care program, the Bureau of TennCare is responsible for payment of Medicare premiums, deductibles, and/or coinsurance for certain low-income Medicare beneficiaries.

How Do I Find Out If I Am Eligible?

Major Medicaid Eligibility Categories in TN