SB 1852

This bill requires the department of finance and administration ("department"") to establish a TennCare buy-in program to provide medical assistance coverage to eligible individuals (""program"") . In order t o be eligible for the program, an individual must meet all of the following criteria (""eligible individual""):  Be a resident of this state .  Be at least 18 but less than 65 .  Not be eligible for medicare .  Not be eligible for medical assistance under any other TennCare eligibility category .  Not be incarcerated .  Meet citizenship and immigration status requirements applicable to medical assistance under Title XIX of the federal Social Security Act .  Pay any required monthly premium in accordance with this below. PREMIUMS AND COST-SHARING. This bill requires the department to establish a monthly premium schedule for the program based on household income as a percentage of the federal poverty level. The premium schedule must (i) b e structured on a sliding scale such that premiums increase with income and (ii) b e designed to ensure affordability while generating revenue to support program sustainability. The department may establish lower premiums or waive premiums for individuals whose household income falls below thresholds established by rule . Premiums must be paid monthly and are due on the first day of each month. This bill authorizes t he department to establish a grace period not to exceed 30 days for premium payment. The department must terminate the coverage of an individual who fails to pay premiums within the grace period. An individual whose coverage is terminated for nonpayment of premiums (i) m ay be subject to a lockout period of up to three months before being permitted to re-enroll and (ii) m ust pay any outstanding premiums before re-enrolling. This bill requires the department to establish cost-sharing requirements, including copayments and deductibles, in accordance with federal law. The cost-sharing requirements must not exceed the cost-sharing limits applicable to medical assistance under Title XIX of the federal Social Securi ty Act . BENEFITS This bill requires the department to enroll an eligible individual who is enrolled in the program in a managed care organization plan. Such enrollee is eligible for the full scope of medical assistance benefits provided under the TennCare program state plan, excluding non-emergency medical transportation assistance. Benefits must be delivered through the same managed care organizations and provider networks used for other TennCare populations, unless the department determines that an alternative delivery system is more appropriate and cost-effective. APPLICATION AND ENROLLMENT This bill requires the department to ensure that an individual can apply for enrollment in the program through the department's online portal, b y mail using a paper application, t hrough a TennCare eligibility specialist, or t hrough authorized community partners and enrollment assistance providers. The department must make eligibility determinations within 60 days of receiving a complete application. Enrollment is effective on the first day of the month following the month in which eligibility is determined and the first premium payment is received. An eligible individual must renew the individual's eligibility annually. The department must conduct annual redetermin ations using available data sources and minimize administrative burdens on enrollees to the greatest extent possible. PROGRAM ADMINISTRATION This bill requires the department to administer the program and has the authority to do all of the following:  Adopt rules necessary to implement and administer the program, including rules regarding a pplication procedures and eligibility verification, p remium payment and collection procedures, e nrollment and disenrollment procedures, a ppeals and fair hearing processes, and p rogram reporting requirements .  Contract with managed care organizations, third-party administrators, or other entities as necessary to implement the program .  Coordinate with the department of labor and workforce development and other agencies to verify employment and income information .  Establish procedures for collecting premiums, including the use of electronic payment systems and automatic payment options .  Implement measures to prevent fraud, waste, and abuse .  Take any other actions necessary to effectively implement and administer the program. FEDERAL APPROVAL AND FUNDING This bill requires the department to timely seek any necessary federal approvals to implement the program, including a state plan amendment under the federal Social Security Act or a waiver under the federal Social Security Act, if required. To the extent permissible under federal law, the department is authorized to seek federal financial participation for medical assistance subject to reimbursement at the federal medical assistance percentage (FMAP) applicable to this state's medicaid program or to allocate shared-savings to support the program. Premium revenues collected under the program must be deposited in a dedicated account and used solely for the purpose of defraying state costs of the program. FISCAL REVIEW AND SUSTAINABILITY This bill requires the department to conduct a comprehensive fiscal analysis of the program within two years of implementation and every three years thereafter. The analysis must include all of the following:  Actual versus projected enrollment and costs .  Premium revenue adequacy .  Federal match rate and any changes affecting federal funding .  Impact on the state budget .  Offsets from reduced uncompensated care costs .  Recommendations for adjustments to premium schedules, eligibility criteria, or other program parameters to ensure long-term sustainability."