TennCare changes: Three plans to offer statewide coverage in 2015

photo Blue Care customer service representative Christina Rogers answers calls at Blue Cross Blue Shield of Tennessee.

BlueCross TennCare plansStarting in 2015, three plans will be available for TennCare recipients across the state:BlueCare. The TennCare plan operated by the state's biggest health insurer, the Chattanooga-based BlueCross BlueShield of TennesseeAmeriGroup. Based in Virginia Beach, Va., the Medicaid provider is a subsidiary of WellPoint, Inc., and serves 2.7 million members in Tennessee, Georgia and 10 other states.UnitedHealth Group. The Minneapolis-based insurer, the nation's biggest, serves 70 million Americans.Source: Tennessee Bureau of TennCareBlue Care at a glanceCompany sponsor: Volunteer Health Plans, a subisdiary of BlueCross BlueShield of TennesseeStarted: 1994Number of standard TennCare enrollees: 220,000 members in East Tennessee and 180,000 in West TennesseeTennCare Select: A specialty product for disabled children and those in state custody for 40,000 membersRevenues: About $2 billion a yearAverage cost: About $225 per member per monthStaff: 900 employees, including 500 in ChattanoogaSource: BlueCross and BlueShield of Tennesee

When Tennessee launched TennCare in January 1994, the switchboard at BlueCross BlueShield of Tennessee was so overwhelmed on the first day of enrollment that operators couldn't even answer all the calls, let alone respond to the applicants' questions.

As the state's biggest managed care organization - and the sponsor of the toll-free phone number for TennCare inquiries - BlueCross was inundated with questions about the new privately operated Medicaid plan.

"It practically shut down the switchboard for the entire company," said Amber Cambron, a 26-year BlueCross veteran who is now chief operating officer for BlueCross's TennCare program. "Everybody here at the time was used to primarily commercial business and group accounts, and to have all these members call in at once - some of whom couldn't read and many of whom were in desperate financial shape - was a real recognition that this was a very different population and a very different business."

BlueCross quickly adapted its Blue Care program for Medicaid recipients and 20 years later TennCare accounts for about $2 billion a year of business for Tennessee's BlueCross plan. Handling claims for the nearly half million Tennesseans enrolled in Blue Care requires more than 900 BlueCross employees, including 500 at the company's corporate headquarters atop Cameron Hill in downtown Chattanooga.

"It's a very hands-on business involving a lot of social work, as well as health care delivery," said Scott Pierce, the chief executive for BlueCross's TennCare subsidiary known as Volunteer Health Plans.

BlueCross has been the biggest managed care organization for the TennCare program over most of the past two decades and was one of three insurers picked by the state to offer plans statewide next year under the latest revamp of TennCare.

Medicaid, which is jointly funded by federal and state governments, is largely administered in Tennessee by managed care organizations that contract with the state to provide medical care at predetermined rates for nearly 1.2 million Tennesseans. In most other states, the government administers Medicaid coverage and the state assumes the financial risk for the costs of care.

Statewide changes

Although BlueCross now serves only TennCare recipients in two of the state's three grand divisions, BlueCross, United HealthCare and a Wellpoint subsidiary known as Amerigroup will each serve the entire state with competitive plans, starting in 2015.

BlueCross also handles claims for disabled and Medicaid recipients in state custody through a separate TennCare Select program.

Darin Gordon, deputy commissioner for Tennessee's TennCare program, said the three insurers picked to administer TennCare next year "have proven their ability to efficiently administer our integrated benefit package of physical, behavioral and long term care services and have shown each is willing to take additional steps to further improve quality." The companies, which were selected from among seven bidders, had to show they would maintain adequate provider networks and provide care within the per-person rates paid for such coverage.

Previously, the Bureau of TennCare awarded regional contracts by selecting two companies to operate in each of the three grand regions - West, Middle and East.

"TennCare is currently working with the health plans to ensure the transition will go as smoothly as possible for our members," Gordon said. "Continuity of care is the utmost concern as we plan for implementation in 2015."

Pierce said BlueCross is eager to resume statewide coverage through its Blue Care program, which the insurer provided prior to the current contracts negotiated in 2008.

Although Medicaid payments to doctors, pharmacists and hospitals are usually less than other insurance plans, most physicians in Chattanooga who accept Medicaid payment rates are included in the Blue Care network. The BlueCross plan includes most hospitals, but not Parkridge, in the Chattanooga area.

BlueCross has lost money on its Blue Care programs in some years and made meager margins in most years. But Pierce said the non-profit insurer sees TennCare coverage as part of its mission to serve the health care needs of Tennessee.

"Medicaid is a volatile market and a low-margin business," Pierce said. "If you are looking for a way to allocate capital, Medicaid is probably not the way to do that. But if you are looking for a way to make a difference for the state, this a business we feel like we need to participate in to serve Tennessee."

Pierce left the No. 2 job in Nashville running the program in state government two years ago to take over the administration of Blue Care. At BlueCross, Pierce's office in next to where many BlueCross customer service representatives talk with TennCare recipients.

"I can hear the conversations going on from my desk, and I like it that way," Pierce said. "It makes me sensitive, not only to what the employees are going through, but what the members are asking about. This is a population that often has a lot of basic questions about the health care system."

State signup woes

While BlueCross prepares to expand its geographic coverage next year, some health care advocates say they are more concerned about current enrollment problems with the program. Starting this year, the state reduced staffing assistance for TennCare signups through the Department of Human Service offices across Tennessee and turned more to the federal web site for signups at www.healthcare.gov.

DHS staffing cuts are leaving some people unable to figure out how to sign up for Medicaid coverage, according to Walter Davis, executive director for the Tennessee Health Care Campaign, a Nashville-based advocacy group.

"We'll have to see how the new MCOs (managed care organizations) work next year, but our immediate concern is the lack of state support for enrollment of TennCare eligibles and the pulling out of staff from DHS offices to help people enroll," said Walter Davis, executive director for the Tennessee Health Care Campaign. "We're seeing a log jam of people trying to get help right now."

Until the state and federal web sites and computer sign-ups improve, TennCare has allowed current Medicaid recipients to maintain their coverage without the normal annual review, at least until April.

The state determines who is eligible to get Medicaid benefits, and Tennessee has resisted participation in the expanded Medicaid program offered through the Affordable Care Act adopted in 2010. Once a person is deemed eligible for Medicaid coverage, he or she has 45 days to choose a managed care organization in Tennessee. If they don't chose within that period, the state assigns TennCare recipients to a plan.

Benefits are identical for each of the three plans, but each insurer has different provider networks.

Hands-on care

Cambron said Blue Care tries to distinguish itself by the customer service provided to recipients. BlueCross employees often make appointments and arrange transportation for TennCare recipients to ensure they get their right health care.

"Some clients don't have cars so we subcontract with transportation services to help people get to their doctors," she said.

After the fire at Patten Towers last year, for instance, BlueCross case managers were dispatched to help those displaced from their apartments would be their prescription drug and get the proper medical care.

"It was a huge company effort working with Red Cross," Cambron said. "Everybody jumped in to help in any way we could."

Contact Dave Flessner at dflessner@timesfreepress.com or at 757-6340