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Tennessee: Session to explain private-duty nursing cuts

By: Emily Bregel
(Contact)

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Marilyn Wilson

Advocates for TennCare enrollees are holding an information session today to help those insured by the state’s managed Medicaid program understand how to appeal impending cuts to private-duty nursing benefits.

Beginning Sept. 7, TennCare will not cover constant private-duty nursing services unless a patient is dependent upon a ventilator for at least 12 consecutive hours each day or has a tracheotomy, TennCare spokeswoman Marilyn Wilson said.

TennCare will provide limited home health coverage to those for whom it is medically necessary, but those hours will be capped.

TennCare will pay for family and loved ones to be trained to supplement that care if more intensive care is needed.

However, “for someone who is very sick and has lots of medical needs with no one to help them, it may be that a nursing home is the most appropriate setting for them to be cared for,” Ms. Wilson said. “But no one is getting a letter saying you must go into a nursing home.”

Patients under 21 are excluded from the limitations, and adult enrollees have until Sept. 17 to appeal changes to their benefits.

Today’s event, organized by the Tennessee Health Care Campaign, is one of a series of training sessions to inform enrollees and their social workers about the upcoming changes and when an appeal over loss of benefits might be successful, said Dan Ramey, a Nashville-based social worker leading the training.

“It’s not a valid factual dispute to say, ‘I need more services than the limits allow me.’ It is important to tell people that, if you’re 20 years old now and you’re getting private-duty nursing, there’s going to be a day of reckoning coming,” he said.

TennCare officials emphasized that appeals will be successful if a mistake has been made, such as if the patient is under 21 and should be exempt from the cuts. TennCare members should not appeal if they simply don’t agree with the cuts to their benefits, Ms. Wilson said.

“The appeals process is there to catch human error,” she said. “To the extent that a TennCare member believes that a factual error has occurred, we absolutely want them to appeal.”

Spending on home health and private duty nursing has been rising, often in the form of 24-hour-a-day care, compelling TennCare officials to propose coverage limits, Ms. Wilson said.

Spending on these services increased 1,250 percent from 2000 to 2007, from $18 million to $234 million, TennCare officials have said.

“What we see is that home health and private-duty nursing services, if we don’t do something about it, are set to be a budget crisis, not just for the TennCare program, but potentially for the entire state,” she said.

The state expects that about 1,000 enrollees are exceeding the new limits and will have to make changes, but only a handful of them are on ventilators, Ms. Wilson said.

Tony Garr, executive director of the Tennessee Health Care Campaign, said the state should wait to implement the cuts until services that could supplant losses of private-duty nursing services become available.

The recent passage of Gov. Phil Bredesen’s Long-Term Care Community Choices Act will provide more options to supplement home care for people who stand to lose services under the new coverage limits, he said.

“Why are these cuts occurring now? Why not wait until this new home and community-based waiver really got up and running so these families get additional support that would make it easier for them to stay in their home?” he said.

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