TENNESSEE CENTER Advocates for Families in Need 2117" Avenue North, Suite 100, Nashville, TN 37219 Phone: (615)255-0831 Fax: (615)255-0354 ail: ceoleman@tnjusticeorg website: www.injustice.org June 7, 2017 VIA ELECTRONIC MAIL Linda Ross, Esq Carolyn B. Reed, sq. Office of the Tennessee Attorney General John Sevier State Office Building 500 Charlotte Avenue P.O, Box 20207 Nashville, TN 37202 Drew Staniewski, Esq Interim General Counsel Division of Health Care Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare Redeterminations of Eligibility Dear Counsel: Tam writing to convey my urgent concerns about significant problems that TennCare enrollees are experiencing in the TennCare redetermination process. These problems compound the compliance issues about which we have previously communicated to you, including most recently the April 14, 2017 letter from Emma Sholl and me to Linda and Michael Bassham regarding TennCare’s failure to properly screen individuals for eligibility in the Disabled Adult Child (DAC) category (to which we have still not received a response). These problems have caused some of our clients to be wrongfully terminated ftom TennCare, and several clients have suffered the foreseeable health and financial consequences of the loss of health coverage. Below I describe some of the more significant problems TennCare enrollees have encountered in the redetermination process and provide some examples. ‘TennCare enrollees terminated despite not receiving a renewal packet ‘The most pressing concern is the number of individuals whose TennCare coverage has been terminated for failure to return a renewal packet despite their reporting that they never received a renewal packet nor a written notice of termination, in violation of 42 CFR. §§ 435.916(a)(3), 435.917, and the Due Process Clause, More than half of the more than 75 individuals who have contacted my office this year with problems arising from the TennCare ‘edetermination process report that they never reccived a renewal packet, and we have receivedreports fiom application assisters statewide of many more instances. Most of these individuals only discovered that their TennCare had been terminated when they sought medical services or pharmaceuticals and were told by the provider or pharmacist that they no longer had TennCare coverage. Thave also recently seen an alaeming spike in the number of individuals enrotled in a Medicare Saving Program (MSP) who have had their benefits terminated despite reporting that they did not receive a renewal packet, Most of these individuals only discovered that their MSP benefits had been terminated when they received notice from the Social Security Administration (SSA) that Medicare premiums, often including past-due premiums from the months since the termination of benefits, would be deducted from their Social Seeutity benefits. These individuals are thus facing devastating and unanticipated reductions in their Social Security henefits that have left some unable to pay rent and other necessities. This problem is exacerbated by the fact that SSA takes at least 30 days, and often much Jonger, to reinstate MSPs in its system, so individuals whose benefits are wrongfully terminated face months of serious deprivation even if they are able to navigate the appeals process—without having received notice of their appeal rights—and get their benefits reinstated. Moreover, individuals who have appealed the termination of their MSP benefits and timely requested continuation of benefits report that their benefits are not being reinstated pending a fair heating, While some of these individuals may have been sent a packet and overlooked or misplaced it, the volume of people reporting the same issue suggests a serious systemic problem. Several of the individuals terminated contacted Tennessee Health Connection (TNHC) and discovered that the renewal packet had been sent to an incorrect address. Some attempted to correct their address with TNHC, only to call back and discover that TNHC still had the wrong, address, We have previously communicated to you our concerns about TNHC’s problems updating enrollees’ addresses (see letters of November 5 and 23, 2015), but these problems appear to be ongoing, Wyatt Qs (DOB @MMPO13) experience is typical of what many TennCare enrollees are reporting to me about the ‘TennCare redetermination process. On February 15, 2017, Wyatt's mother, Amber was notified by her son’s pharmacist that Wyatt's TennCare coverage had ended. She had not received a renewal packet or a written notice of termination from TennCare. She called TNHC the same day to find out what happened and to appeal Wyatt's termination, She was told by the TNHC representative that a renewal packet had been sent to an address where the GMM family had not lived in over two years. She was told that Wyatt's coverage had ended on February 5, 2017, That day, Ms. Q¥impcalked with multiple ‘TNHC representatives and updated her address four separate tines. Between February 15 and February 21, 2017, Ms. @ilispoke with 21 TNHC representatives and updated her address a total of 15 different times, because nearly every time she spoke with a different representative, they told her they had an incorrect address on file. She occasionally would speak with a representative with the correct current address, only to be transferred to another representative who still had the incorrect address or contact informationOn February 20, 2017, Ms. Ql was contacted by telephone by an Appeals Representative, who informed her that Wyatt’s coverage had been temporarily reinstated and that anew renewal packet had been sent. Ms. QB confirmed the contact information on file, which was correct. The Appeals Representative told Ms. (to complete the packet when she received it and reuirn itto the address provided in the packet. Three weeks later, the packet had still not arrived, but on or around March 15, 2017, Ms. EEE ceceived new TennCare Amerigroup cards for the family. These were sent (o the correct address, including the correct apartment number. On April 1, 2017, Ms. @iiBreceived a letter from TennCare stating that TennCare had changed her address in its records and providing the correct address, including the correct apartment number. But only three days later, on April 3, Ms. (received @ call from a ‘TennCare representative named Yasmine who asked if Ms. had received her renewal packet. When Ms. 9 responded that she had not received it, Yasmine told her that Ms. GEEEBD xc! n0 provided an apartment number, even though Ms. had received correspondence from Amerigroup and TennCare sent to her address, including the correct apartment number. Ms. informed Yasmine that the family had moved again on April 2, 2017, and provided her with updated contact information. Yasmine told Ms. @qmthat she would send her a new renewal packet by overnight mail to the updated address. Ms. lB reccived the renewal packet the next morning, April 4, 2017. That afternoon, she received a notice from the TennCare Eligibility Appeals Unit dated March 31, 2017, stating that she must return her renewal packet in 90 days or Wyatt’s coverage would end, It also said that she could not move forward with the appeal until she had explained what mistekes she thought TennCare had made. In response to the March 31 notice, Ms. QJ sent an email on April 5, 2017, to the bility Appeals Clerk at appeals.clerk.tenncare@tn.gov explaining in detail that she had not returned the initial renewal packet because she had never received it because it was sent to the wrong address, On April 17, 2017, Ms. Qlireceived a call from Yasmine, the TennCare representative she had spoken to previously. Yasmine asked whether Ms. had received the renewal packet. Ms. @ilexplained that she had received the packet and asked whether ‘TennCare had received her email explaining why she had not returned the packet. Yasmine replied that TennCare had received the email and then asked Ms. @JMto return the completed renewal packet the next day, April 18, only 14 days after she had received the packet. Ms. am explained that she could not return the packet the next day because she was out of town with her family until April 23, Yasmine put Ms. @¥lion hold and wien she returned to the call told Ms. Nickle that she had to return the completed packet by April 24 or Wyatt’s coverage would be terminated on that day. Yasmine told Ms. (thst she has “had more than plenty of time.” On April 23, 2017, Ms. Ql received a letter from TennCare dated February 24, 2017, Scht (O Apt 1021, Franklin, TN, 37069. The GB family did previously live 2 ITD but the apartment number—Apt 1021—on the February 24 letterwas from a subsequent address in Spring Hill, TN. The letter acknowledged receipt of Ms. EBD: appeal of the termination of Wyatt's coverage. On May 4, 2017, Ms. QI faxed a completed renewal packet for Wyatt to TennCare. On May 15, 2017, she received a letier stating that Wyatt's TennCare coverage had been terminated because she never returned the renewal packet and did not provide an explanation of the mistakes she thought TennCare had made, On May 16, 2017, Ms. MF filed an appeal of Wyatt’s termination, She followed up her appeal with a call to TNHC on May 22, 2017. In that call, she was told that TNHC did not have @ record that she had submitted a completed renewal packet to TennCare and that she had 90 days after December 30, 2016 to submit a completed renewal packet. TNH confirmed that TennCare had received Ms. Qs appeal. ‘On May 23, 2017, Ms. mg called TNHC. Once again, Ms. Ql had to update her address because TNHC still had the incorrect address on file. She spoke a supervisor named Lee who told Ms. (that she had not submitted the required documents in time, and that as a result, her son would not be reinstated in TennCare, Leo also told Ms. Ql she had no right to a hearing to review her son’s eligibility On May 25, 2017, Lee called Ms. @JimBand left a voicemail message. Ms. returned Lee’s eall, and spoke with a TennCare employee named Claudia. Claudia told Ms. (GHEEB that an attorney representing TennCare had reviewed her case, and determined that her only option was to apply for health insurance through the federal Marketplace. She has received no further communications from TennCare, Other individuals who have discovered that their TennCare coverage has been terminated for failure to return a renewal packet despite reporting that they never received a renewal packet nor a written notice of termination include: + Michael ND (DOB QIN 1974): Michae! (learned that his TennCare was being terminated from his dialysis doctors roughly a week before his coverage was scheduled to end. Mr. (reports that he never received a renewal packet or a written notice of termination before his coverage was terminated on May 25, 2017. Mr. zz» relied on TennCare to cover his rides to and from dialysis treatment, Mr, Marbut has filed an appeal and requested continuation of benefits, but TNHC has been unable to confirm that his coverage has been reinstated. + Jacob (ED (DOB 2008): Jacob QED was terminated from TennCare in January 2017, a faet his mother learned at her pharmacy when she tried to fill hi prescriptions that month. His mother reports that she never received a renewal packet ot a written notice of termination before his coverage was terminated, Ms. (EB requested anew renewal packet from TemnCare after she learned of her son’s termination, Ms. (ERED cid 10% receive this second packet until May 2017. However, she found the ‘original packet mixed in her neighbor’s mail in February 2017. She submitted a completed packet to TennCare on February 10, 2017. However, her son’s TennCare wasnot reinstated until May 23, 2017. While her son’s TennCare was terminated, Ms. EB 24 (0 pay hundreds of dollars for his medication out-of-pocket, which the family could ill afford. + Kristen QM (DOB @/1994): Kristen QB discovered via an automated voice message left on September 12, 2016, that her TennCare coverage had been terminated for failure to return a renewal packet. She reports that she never received the renewal packet hor a written notice of termination prior to the voice message. She contacted TNHC and ‘was informed that the renewal packet had been sent to the wrong address. She attempted to correct her address with TNHC and requested that a new renewal packet be sent. This second packet was again sent to the wrong address. While she was without TennCare, she could not afford to have a birth control implant removed. She became pregnant with implant stil! in place and had a miscarriage. Renewal packet for individuals enrolled in MSPs does not specify that the packet is for MSP renewal Some individuals whose MSP benefits have been terminated did receive a renewal packet but disregarded it because the notice is misleading. The first page of the notice is headed with the statement “It’s time fo renew your TennCare!” It docs not mention eligibility for MSPs until the middle of page 2. Many individuals enrolled in MSPs do not think of themselves as “having ‘TennCare,” only as having QMB or SLMB, and thus disregard the packet. TenmCare should, at a minimum, provide individuals enrolled in MSPs with a notice that clearly informs them that the renewal pertains to their MSP eligibility, Kathryn QI (DOB GEE 1960), for instance, received notice from SSA that ‘TennCare would no longer be covering her Medicare Part B premiums and that SSA would be deducting $407 from her lune SSDI check to backdate premiums, leaving her with just $813 for the month, not enough to pay her rent. After speaking with someone in my office, she was able to find a letter and a renewal packet from December telling her it was time to renew her ‘TennCare. She explained that she did not fill out the packet because she did not know she was on ‘TennCare until she spoke with our office on June 1, 2017, Ms. QNEMNB suffers from PTSD and severe depression and relies on her MSP (o pay for her medications. Because she has been unable to afford her medication without her MSP, she has become severely depressed and reclusive. ‘TennCare enrollees terminated despite returning renewal packet Thave also received multiple reports, both from TJC clients and application assisters around the state, of individuals who have retumed their completed renewal packet by the stated deadline but have nevertheless had their coverage terminated for failure to return the renewal packet. Often individuals have retained fax receipts proving that TNHC received their packets, but TNHC still denies receiving them. I alerted you to problems with TNHC’s mishandling of documents submitted by applicants and enrollees in 2015, but these problems have not been remedied.Miche! QI (DOB QI has dementia and a range of serious medical needs. He lives with his elderly mother and disabled brother. He had been enrolled in CHOICES Group 2, until his aunt, who does not live with Mr. M9 but visits the family regularly, noticed that his home health aides had stopped coming, She called my office for assistance, and a client advocate asked ifthe family had received a renewal packet. She was then found the packet in Mr. home, completed it, and faxed it to TNHC on March 13, 2017. She called TNHC one month later and was told that the packet had not been received. She then sent TNHC a fax confirmation page showing that that packet had been faxed successfllly. She also sought help from the AAAD, who helped complete a second renewal packet on Mr. behalf. TNHC has confirmed receipt of the second packet on May 3, 2017, but even though Mr. QM aunt sent proof of faxing the first packet, TNHC continues to report that it only received the second packet, and Mr. IMB continues to go without coverage, Since his coverage has been {ermninated, he has fallen, been hospitalized because of a head wound, and has needed more caregiving than his elderly aunt ean provide. needed to redetermine ‘TennCare enrollees not told what additional li Multiple individuals who timely returned @ completed renewal packet subsequently received requests for additional information from TennCare, When they have contacted TNH and/or the TennCare Redetermination Unit to seek clarification as to what additional information is needed, neither has been able to provide them with any clatification, This problem is especially concerning for CHOICES enrollees facing redeterminations of eligibility, who may face particular difficulties gathering financial documents. By failing to provide individuals sufficient information about their rights and responsibilities, TennCare is violating 42 CFR §§ 435.905 and 435.908(a), Billic ND (DOB GEE for example, is a 48-year-old TennCare enrollee who has had several strokes and is bedridden. Ms. (JHMM was approved for the CHOICES progeam in September 2016, but in December 2016 she received a notice that her TennCare coverage would be terminated because she had allegedly failed to provide certain financial documents necessary to redetermine her eligibility (though she had just been approved for CHOICES two months before). A client advocate from my office assisted Ms. (land her family and cliscovered that renewal packet for Ms. (Jphad been sent to the wrong address in September, and another packet was sent in November. Ms. iii was only able to complete and return the packet with significant help from her care coordinator. Only after filing an appeal with the assistance of my office was Ms. lable to determine what additional documents she needed to provide, Many of the documents TennCare sought were written statements confirming that other documents did not exist such as, “My only bank account is Commercial Bank,” and “We do not have any health insurance premiums.” Similar written statements had not been required for Ms. QJM s initial approval for CHOICES a few months earlier, (GEE (1.08 GEBL989) received a renewal packet in late August or early September, 2016, She completed it and retuned it timely by mail. When she did not get any further notice, she called TNHC and was informed that the completed packet had not been received. She requested that another packet be sent, completed it, and retuned it by fax. Shecalled TNHC and confirmed that the fax had been received. Nevertheless, she was informed by her doctor at a subsequent visit that she no longer had TennCate, She reports that she had not received a written notice of termination. Ms. QM iled an cligibil November, 2016. After filing the appeal, she received notice informing her that her renewal packet was being reviewed, that she would receive a decision soon, and that her appeal was closed, On January 9, 2017, Ms. QE received notice that she did not qualify for TennCare, She called TNHC to find out the reason for her termination and what information she needed to submit to restore her coverage, but the person with whom she spoke was unable to tell her. Ms. (EEE hac already sent proof of her only source of income, her son’s SSI check, to TennCare. She finally contacted my office, where we assisted her in preparing a written, signed and dated statement that she was unemployed that detailed the length of her unemployment, After submitting the statement to TennCare in February, Ms. QIN s coverage was finally restored. Ms. QI was told that her coverage would be backdated to the date she first sent in the renewal packet. However, after her coverage was restored, multiple medical providers contacted her demanding hundreds of dollars in payment. In late March, 2017, she learned that her TennCare coverage had not been backdated. Over the next two months, a client advocate with my office made repeated attempts to resolve this issue by contacting TennCare, TNHC, and Ms. QQ managed care provider. On May 25, 2017, Ms. NF managed care provider informed my office that her coverage had been backdated. Inconsistent Redetermination Results for Household Members Based on the Same Information T have received multiple reports of individuals having their TennCare coverage terminated despite other members of their household being approved for continued coverage based on identical information provided in the completed renewal packet. These inconsistencies raise fundamental questions about the ability of TennCare and its contractors to fairly and reliably evaluate enrollees under all potential categories of eligibility, as required by 42 U.S.C. § 18083 and its implementing regulations, 42 CFR §§ 435.911 and 435.916(1). This problem is complicated by the fact that TennCare and TNHC are giving conflicting information about renewal packets for households with multiple individuals. The recorded telephone hold message for TNHC states that households need only return one packet for all household members. However, the March 2017 TennCare Advocates Newsletter states, “Please note packets are mailed to individuals not families or cases. So, if there are multiple individuals in one household receiving TennCare services they will all receive an individual packet.” Blake (DOB (HBB 2000) is a minor child in a family with an annual income of $8,000. His family received a single redetermination packet from TennCare, completed it, and sent it to TennCare. In October 2016, TennCare terminated every member of the family’s coverage except the father, The other family members appealed within ten days, and they received separate redetermination packets for each member of the family. The family then completed each redetermination packet and sent them to TennCare. TennCare then approvedcoverage for every member of the family except Blake Qi) The amily appealed this decision within ten days. On January 11, 2017, the family received a notice from TennCare that they had received Blake (js redetermination packet and would review it for eligibility. Then, on March 24, 2017, TennCare sent a letter to the family that said the mp family had failed to respond to a purported January 11, 2017 letter requesting more facts, and that they were denying Blake (coverage as a result. The (ll family appealed this decision within ten days. ‘Throughout October 2016 to March 2017, the amily also contacted TennCare’s contractor, Maximus, several times by phone. In one of those contacts by phone, a Maximus supervisor named Guillermo assured the jy family that they had submitted all of the income information that they needed, Despite this, on March 29, 2017, the family received a call from William saying that TennCare needed a Schedule C from the father of the family to determine eligibility. The family submitted a Schedule C to TennCare as well as the father’s complete 2016 tax retwum. On April 4, 2017, Blake's Legal Aid attorney, Russ Overby, contacted TennCare and. requested Blake’s coverage be reinstated. The letter noted that at this point, Blake Ql a minor child, had gone approximately six months without TennCare coverage after every other member of his family had been approved for TennCare coverage. The letter further noted that at the time the letter had been sent, the family had incurred significant out-of-pocket medical expenses. In response to this letter, on April 17, 2017, TennCare restored Blake Qs coverage. Bla QE (DOB @N2005) is a minor child with multiple health issues. He lives with his mother, stepfather, and three minor siblings. His family received a TennCare renewal packet in or eround February 2017, Blake's mother, Pamela, completed and returned the packet to TennCare. She subsequently received a notice terminating coverage for all six members of the family. She filed an appeal in April 2017. On May 22, 2017, she received two notices, one stating that that Pamela and her husband were eligible and reinstating their coverage, and the other stating that all four children were ineligible and closing their appeal. A few days later, Pamela received a letter stating that two of her children, Landon (NN 2111 Wyatt HM were approved for coverage. However, the notice requested additional information regarding household income to determine eligibility for Blake and Caleb 7 On May 31, 2017, Pamela called TNHC and was told that no more information was needed and that all six family members should have been approved. Blake and Caleb continue to go without coverage. Blake has also had to go without his bi-monthly home therapy visits as well as his monthly regular therapy visits since his TennCare coverage was terminated. ‘The family has had to pay between $85 and $110 per month out of pocket for Blake's medication due to the loss of coverage. Additionally, Blake was unable to see his primary care physician for an upper respiratory infection. The family instead had to pay $85 out of pocket to take him to an urgent care facility. Blake has also had to forego multiple neurological tests his doctor has recommended.Other Issues Clients and assisters statewide report the following ad redetermination process: ional problems with the * Wait times on calls to TNHC regularly exceed one hour and often longer; * TNH is often unable to confitm if it has received completed renewal packets or additional requested information; * Authorized representative forms are taking up to two months to process, so individuals with authorized representatives are unable to get timely information about the redetermination of their TennCare eligibility from TNHC; and, + TNHC is regularly discouraging individuals from filing appeals by telling them that they should instead eall the Redetermination Unit to check on the status of their renewal packets. As your clients ave aware, TennCare enrollees include many extremely vulnerable individuals for whom any interruption in TennCare coverage can be expected fo cause serious harm, The federal laws cited above were established to safeguatd enrollees from such foreseeable harms, while ensuring that their eligibility is fairly and accurately determined. It ‘would be dangerously irresponsible for TennCare officials to terminate coverage for any enrollee ‘without respecting all federal laws and constitutional protections that must attend such an action. | am requesting assurances that the state will not proceed with terminations until the violations described above have been corrected. This corrective action should include, at a minimum, taking reasonably necessary steps to communicate about the redetermination process to individuals who do not return renewal packets, including: Use of email where addresses are available; * At least three phone calls on different days, at least one of which should be after normal work hours, to any phone numbers on record with the state or its agents (e.g., SNAP or ‘TANF records, wage reports, TennCare managed care contractors or their providers, etc.); and, + Re-mailing (o any postal address on record with the state or its agents. In addition, TennCare shou! * Revise the notice it sends with the renewal packet to MSP enrollees so that it clearly notifies these individuals that the packet concems their eligibility for MSPs, not TennCare; and, © If TennCare needs additional verifications to determine an individual's eligibility, TennCare should include a reasonably specific description of the information needed in the notice requesting the information, In addition, 1am requesting information about the redetermination process that will allow me to better assess the nature and extent of the problems. Please consider this letter a request for documents under the Tennessee Open Records Act, Tenn, Code Ann, § 10-7-101 et seq.Will you please provide me the following information and/or documents? All of these requests are limited to the time period since TennCare recommenced its redetermination process in 2016. 1, The total number of i viduals who have been terminated from TennCare each month. 2. The total number of individuals who were enrolled in MSPs who have been terminated each month, 3. The total number of individuals who were enrolled in CHOICES who have been terminated each month. 4. The total number of individuals who have been terminated from TennCare for the alleged failure to return a renewal packet. 5. The total number of individuals who were enrolled in MSPs who have been terminated for the alleged failure to return a renewal packet. 6. The total number of individuals who were enrolled in CHOICES who have been terminated for the alleged failure to return a renewal packet. 7, ‘The number of individual who have been terminated from TennCare for the alleged failure to respond to requests for additional information or verifications. 8. The total number of individuals who were enrolled in MSPs who have been terminated for the alleged failure to respond to requests for additional information or verifications. 9. The total number of individuals who were enrolled in CHOICES who have been terminated for the alleged failure to respond to requests for additional information or verifications. 10, Any audits, reviews, or quality control measures conducted related to the TennCare redetermination process. 11, Any reports, memos, or other documents reflecting problems with TNHC’s performance in (@) maintaining and updating correct addresses for TennCare enrollees; (b) answering telephone calls in a timely manner; and/or (3) providing accurate information about the ‘TennCare redetermination process to TennCare enrollees. This request is limited to system-level reports, memos, or other documents and does not include documents solely involving individual eases, 12, Copies of all notice templates used in the redetermination process. If you deny all or any part of this request, please cite each specific exemption you contend justifies your refusal to release the information,Pursuant to Tennessee Rule 1660-03-01-.05, I request a waiver of fees for any searching, reviewing, and duplication because disclosure of the requested records is in the public interest and is likely to contribute significantly to public understanding of the operations or activities of the government. TIC is not engaged in any commercial enterprise related to this, request. Should you deny this waiver request, please notify me if the searching, reviewing, and duplication fees exceed $25.00. Ifyou have any questions, please do not hesitate to contact me. Thank you for your consideration, I look forward to heating from you. Sincerely, (pon Chu ae Christopher E. Coleman ul