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TennCare Guide

Tennessee administers the federal Medicaid program through TennCare, the state's effort to expand health care coverage to low-income patients. With a budget of about $8 billion, TennCare provides coverage to 1.2 million citizens in the state. The comprehensive health care system provides for a wide range of medical needs, from physician visits and prescriptions to the purchase price of medical devices. To qualify for TennCare, households must pass income tests that prove their financial need.

  1. Medical Benefits

    • Although TennCare provides 10 different coverage packages, most recipients fall into two groups: children under 21 who don't receive Medicare and adults age of 21 and older who don't receive Medicare coverage. Qualifying children receive full benefits of all types, from physician services, lab fees and medical supplies to chiropractic care, vision care and coverage of emergency transportation. Qualifying adults' benefits are more limited, with dental and chiropractic care not covered, and limits on in-home nursing services and TennCare's vision plan only covers examinations, not the cost of corrective lenses.

    Medical Co-payments

    • As TennCare stresses managed care, beneficiaries never pay co-payments for preventive care services, such as vaccinations, pregnancy care, pediatric check ups, mammograms, prostate examinations and pap smears. Co-payments on non-exempt treatment varies upon the recipients's income level. All TennCare beneficiaries who earn less than the federal poverty level for a household of their size are exempt from co-payments. Beneficiaries who earn between 100 percent and 199 percent of the poverty level pay $5 for primary care, specialist and inpatient hospital admission, and $10 for emergency room visits, as of May 2011. Beneficiaries who earn 200 percent of the federal poverty level or more pay $10 for primary care, $20 for specialist care, $50 for emergency room visits and $100 for inpatient hospital admission.

    Pharmacy Benefits

    • As with medical benefits, qualifying children who are younger than 21 receive unlimited pharmacy benefits. Qualifying adults receive full coverage on the first five prescriptions or refills on prescriptions each month. Only two of those prescriptions may be brand-name drugs in most circumstances. Adults must pay a $3 co-pay on many prescriptions, although generic drugs, birth control and medications administered in an emergency are exempt from pharmacy co-payments. There is no limit on monthly co-payment amounts for adult TennCare members.

    Eligibility

    • Two primary types of TennCare services are available. TennCare Medicaid is only available to families and individuals who qualify for Medicaid, including minors, pregnant women, single parents, Supplemental Security Income recipients and people who live in nursing homes. Income tests and savings levels apply differently to each group eligible for TennCare Medicaid. TennCare Standard extends to children under the age of 19 who don't have access to health insurance and live with a family that earns less than 200 percent of the federal poverty level.

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