Part of the intent of the Affordable Care Act was to create what's called the "no wrong door" rule.
That means people are supposed to be able to submit a single, streamlined application for all potential sources of health coverage, applying online, over the phone or in person through both federal and state agencies.
But in Tennessee -- where in-person Medicaid assistance has been exiled from local offices, where a new state computer system to determine eligibility remains unfinished and where state officials say they struggle to get accurate information from federal officials -- some Medicaid applicants say the process is more like an ever-revolving door.
They keep pushing it in circles, but it never really opens.
"They just send you from one place back to the other. It is a nightmare," said Rebecca Mulkey, a Chattanooga woman who has been struggling to get her mother set up with long-term-care coverage through TennCare, the state's Medicaid program
"The right hand does not know what the left hand is doing. There are too many agencies involved and it's a mess."
Soon after the New Year, volunteers and workers involved in helping Tennesseans enroll for ACA insurance began noticing a spike in people coming into their offices.
They were people struggling with complex questions and problems with TennCare: Pregnant women and new mothers trying to get coverage for their newborns. Elderly people struggling to access Medicare savings programs they typically handled with the state agency. And families who said they had been told by federal authorities that they were eligible for TennCare -- but hadn't heard anything back from the state for weeks.
Many told stories of being stuck in a bureaucratic spin cycle.
One Nashville man, who asked that his name not be used, was on TennCare for two years with his family. Last fall, he got a notice ordering him to reapply by the end of the year.
He did, but in January he got a letter saying his coverage had been terminated.
Confused, he went to his local Department of Human Services office, where he had always gone with his TennCare questions.
But there, staff members pointed to a computer kiosk and told him he would have to apply through the federal health insurance marketplace, Healthcare.gov.
"They just told me that they don't handle that anymore. It was all very confusing," he said.
After several hours on the phone with federal marketplace officials, a representative confirmed he was eligible, and said that TennCare representatives would be in touch about enrolling him within a few days.
But he never heard back.
He called the marketplace, which sent him to a state help hotline, which then told him to apply on the marketplace.
Finally, he called Gov. Bill Haslam's office, and was directed to someone in a TennCare response unit -- who again told him he needed to apply to the marketplace.
During an eventual conference call with federal and state representatives, he was told that some boxes on his application had not been checked. He was told to get income records from another state agency, which told him it might be 45 days before he heard back.
"There's a breakdown between the state and the federal government," the man said. "I've spent just about every waking moment on the phone trying to get it sorted out."
Behind the confusion is a series of major TennCare changes that have gone largely unheralded amid the hubbub of health reform.
The state is still trying to finish a $35.7 million computer system, called the "Tennessee Eligibility Determination System," or "TEDS," which will make TennCare enrollment decisions according to a new federal calculation, called the Modified Adjusted Gross Income.
Originally expected to be completed last year within what state officials called an "impossible" federal timeframe, TEDS still has no projected completion date.
Until that's finished, the state is directing all TennCare applicants to the federal marketplace -- chiefly via Healthcare.gov.
But not all applications from the site are being fully transmitted, because of problems with how the federal system is communicating with the TennCare system. In many cases, those applicants don't know they're in limbo, state officials acknowledged.
Meanwhile, the state removed all in-person TennCare services from its DHS offices, saying that offices were no longer connected to TennCare under the new system.
"Tennessee is the only state in the country that has said to its citizens, 'There's no opportunity for you to apply in-person' and then sends you to the federal marketplace," said Gordon Bonnyman, staff attorney with the Tennessee Justice System, a Nashville-based advocacy center.
TennCare officials defend the current enrollment process, saying it is the most efficient and convenient way to handle signups while they finish TEDS.
"While we realize the implementation hasn't been 100 percent perfect, we think long term this is the best opportunity for individuals to have as many application opportunities as possible," said Tracy Purcell, director of member services for TennCare.
But healthcare advocates say thousands of people could fall through the cracks or be left in limbo, unsure of their enrollment status.
"It's running people in circles," said Walter Davis, director of the Tennessee Healthcare Campaign, a Nashville-based nonprofit.
TennCare officials say most people who have applied for the coverage through Healthcare.gov and been found eligible have been enrolled -- about 40,000 between Oct. 1 and Feb. 14, Purcell said.
But the office would not say how many applications are currently unanswered or in limbo, saying they are "in discussions" with the U.S. Centers for Medicare and Medicaid Services about those cases.
TEDS is now about 60 percent complete, said Purcell -- but it will not be finished in time for the March 31 ACA enrollment deadline.
She points to the botched launch of Healthcare.gov as the chief reason for thorough testing of TEDS.
But Bonnyman calls the claim "ironic."
"It's unfortunate that the state has been so critical of Healthcare.gov, but as a result of its own problems and decisions, has forced Tennesseans to rely on that site," he said.
In the meantime, said CMS spokeswoman Emma Sandoe, the federal agency is "actively working" with states that are still developing such systems to ensure correct information is transferred from Healthcare.gov.
But some applications arrive from incomplete. In such cases, the state has to put the application on hold until CMS provides more information, Purcell said.
Tennessee is not the only state that has struggled with such a disconnect. Last week, the Atlanta Journal-Constitution reported that 90,000 Georgians who applied for coverage on Healthcare.gov have not been enrolled for Medicaid because of missing or unreliable data.
What sets Tennessee apart are its decisions to send TennCare applications through the federal marketplace, and to remove all in-person assistance. Georgia still has both.
National experts in state health policy say Tennessee's stance is unusual.
"Most states understand they are obligated to have an independent, functional online application and way for people to access the Medicaid eligibility process separate and apart from Healthcare.gov," said Alice Weiss, program director at the Washington, D.C.-based National Academy for State Health Policy.
But, Weiss adds, that does not necessarily mean that Tennessee is out of compliance with federal guidelines. With all of the problems states are facing with these changes, compliance has become "very gray," she said.
While state officials say enrolling online or by phone is convenient, advocates say a large number of TennCare applicants with disabilities or limited computer skills need face-to-face help.
Purcell said TennCare is considering adding in-person help for a "small number" of people who may need it, but added that critics "are underestimating the capabilities of our enrollees."
She also pointed to the state's new call center, called the Tennessee Health Connection, which is meant to provide personal TennCare help.
In many cases, though, advocates and applicants say that the Tennessee Health Connection simply sends people to Healthcare.gov, or to federally-funded navigators.
In turn, navigators say they were unprepared for the many complex TennCare questions they now encounter.
"The federal training for navigators includes little to no TennCare training," acknowledged Katherlyn Geter, who oversees navigator efforts for Erlanger Health System. "It has added a layer of confusion. Of the 20 people I saw last week, probably 10 to 15 of them are TennCare-specific inquiries."
It's a burden, Bonnyman contends, that should be the state's.
"Even if we had all the navigators in the world -- and we only have very few, and they are overwhelmed -- their responsibility is not to do TennCare's job," said Bonnyman.
During a presentation at Vanderbilt University's Annual Social Work conference on Wednesday, Davis called on the state to return TennCare staff to face-to-face settings.
"It is time for TennCare administrators and the governor to acknowledge the mistakes that were made," he said. "Make TennCare work and we will be behind you."
Contact staff writer Kate Harrison at firstname.lastname@example.org or 423-757-6673.