Health Care Story of the Week - 12/30/09

This fall began like any other for ten year-old Darius Richardson. In September, he started practicing with his football team for the season’s opening game. But then, Darius found out that he had brain cancer and would have to have an operation. Darius has been serious about sports since age five. Football, basketball, and baseball are among his favorites.

Darius lives with his single Mom, Trina Parker, who worked full-time until Darius got sick. The cancer began forcing Darius to miss football practice and school due to chronic headaches and severe weight loss. She had to cut her work hours in half so that she could care for him, leaving both her and her son ineligible for her employer’s health insurance.

Darius and Ms. Parker didn’t think things could get much worse. Then, TennCare told him he was going to lose coverage the day before he was to have the tumor removed. Without insurance, Vanderbilt would not do the operation. Ms. Parker asked the Department of Human Services (DHS) for help, but nothing happened. “I didn’t know who else to turn to,” she said. Then, a social worker told her about the Tennessee Justice Center.

When Ms. Parker called TJC, we realized immediately that TennCare had made a mistake in calculating Darius’s family’s income, and that he should stay on TennCare. We helped Ms. Parker file an appeal, allowing Darius to keep TennCare during the appeal. The surgery went smoothly, and Darius went home with his Mom about a week later.

Despite everything, “Darius is in good spirits. The doctor explained everything and he understands that the treatment is to get rid of the tumor,” said Ms. Parker. “He has a really good family-based support and church.”

But her fight wasn’t over yet. Darius’s cancer was worse than doctors had thought. A few days before Darius was scheduled to return to the hospital for chemotherapy, DHS told Ms. Parker they were going to close Darius’s TennCare case. Ms. Parker called TJC again. We wrote the Case Manager a letter reminding him that DHS rules required him to keep Darius’s case open.

DHS kept the case open, and later approved Darius’s TennCare application. He is currently at the hospital, receiving his first round of chemotherapy treatment.

Without a law firm's help, Darius would not have been able to get the surgery he needed to live, even though he still had a right to TennCare coverage. “I don’t know what else I would have done,” said Ms. Parker.

When Darius and Ms. Parker needed it most, our healthcare system was not there for them. “It’s clear to me that the system is broken,” said Ms. Parker. “I pray that we can work together to fix our country’s healthcare, so other families don’t have to go through the same struggle we did just to get basic care.”

Health Care Story of the Week - 12/16/09

Ms. Benson adopted her son, Zachary when he was 16. Zachary loves skateboarding and outdoor activities like caving, rock climbing, and paintball; he excels in school. Like any parent, Ms. Benson makes sure that Zachary gets appropriate preventive care and treatment. Zachary was adopted from the custody of the Department of Children’s Services, and he was guaranteed enrollment in Medicaid with his adoption. Ms. Benson was eager to adopt but simply could not afford health insurance for an additional family member.

For as long as Ms. Benson has been caring for Zachary, including when he lived with her as a foster child, Zachary’s doctors have reported that they were not being paid. In September, one of Zachary’s providers informed Ms. Benson that if TennCare continued to not pay for services for Zachary, Zachary may be turned away or Ms. Benson might be required to pay for services up front.

Since TennCare is required by law to pay all medical expenses for enrolled children, Ms. Benson decided to investigate the problem. She soon learned that Zachary was somehow still listed as enrolled in the insurance policy his stepfather had through his employer, even though parental rights had been terminated and Zachary had become a full ward of the state some years previously. Consequently, when providers billed TennCare, TennCare would kick the bill back, stating that they were not the primary insurer for Zachary. The bills got bounced around from insurer to insurer without any payments being made.

Since Zachary first came to Ms. Benson’s home, she has struggled with trying to get TennCare to pay for Zachary’s health care needs. Repeated phone calls to DCS, insurance companies and health care providers proved fruitless. In addition to this clerical error, Ms. Benson faced two other challenges related to Zachary’s health care: she had submitted paperwork to have Zachary’s name changed several months ago, and she had not received a new TennCare card reflecting Zachary’s new name, despite her request.

TJC regularly gives presentations to foster parents throughout the state, to inform them of their foster children’s rights under TennCare. TJC specifically targets these groups because most foster children are on TennCare. Ms. Benson met TJC advocate Susanne Bennett at one such event in Cookeville. Ms. Benson informed Susanne about the problems she was having getting care for Zachary due to the administrative glitch she had been unable to resolve for years. Ms. Benson told Susanne, “I am just concerned that the providers get paid so that my son is able to get the medical care he needs.”

On November 2, 2009 TJC wrote a letter to TennCare’s lawyer’s invoking TennCare’s pay and chase policy. This means that TennCare had to make sure Zachary’s providers got paid, and, if a different health insurance policy was responsible for Zachary’s bills, TennCare would have to “chase” it for reimbursement. In late November, Ms. Benson learned that Zachary’s provider had been paid by TennCare, and the charges were paid under Zachary’s new name.

The state’s lawyers responded, stating that these problems would be resolved. When Ms. Benson heard that Zachary’s case was finally being handled appropriately, she said, “I am thrilled that I can take him to the doctor now that I know they won’t have trouble getting paid by TennCare. I was at my wit's end. It was like running on a treadmill. Everyone I called passed the buck and no one tried to fix this problem.” Thanks to Ms. Benson’s tireless advocacy for her son, they no longer have to worry about whether his doctors will continue to see him.

Health Care Story of the Week - 12/10/09

It was only through Judy's diligence that her 12 year old son, Chase, received the care needed to correct a serious vision problem that limited his activities and ability to read. Chase’s optometrist prescribed vision therapy. After two months of therapy, his eyesight had improved significantly. However, at that point, less than halfway through his program, Judy received notice from TennCare that it would not pay for the treatment. She decided to pursue the care which was bringing her son’s world into focus.


After she received the TennCare denial letter, Judy contacted the Tennessee Justice Center, asking for assistance in presenting her case to TennCare for her son’s vision therapy. Between working at the YMCA and caring for Chase and his sister, she needed help in navigating the TennCare system. TJC explained what Chase’s rights are, and helped her file an appeal as well as supplementing Judy's appeal with a letter to the state about Chase’s situation.

In response to TJC’s letter, TennCare said that the vision therapy was experimental and denied it. The only alternative that TennCare offered was bifocals, which wouldn’t actually correct Chase’s eyes. Judy was determined to find a way to continue the therapy that was helping her son. Since Chase could not continue seeing his doctor, with the doctor’s guidance, his mother performed the vision therapy at home consistently. Through prayer, tenacity, hard work, friends’ support, and with two months of doctor-guided therapy, Chase’s vision is now normal.

“I wish TennCare would cover the treatment that benefited my son and other alternative treatments that could benefit other children,” said Judy. “Instead of facing a lifetime of vision problems, Chase’s vision is normal because of the therapy. A few months of vision treatment seems more medically and financially wise in the long run, instead of the bifocals offered by TennCare. Over the years, bifocals would cost more.”

Judy added, “At first I felt like I was all by myself, thinking ‘am I going crazy?’ not having anyone’s support legally. Because of TJC, I did not feel alone in navigating through the legal system. Thanks to all at TJC!”

Health Care Story of the Week - 12/2/09

Vicie loves children, and has adopted three special needs children, including her son Trevor. Trevor is extremely medically fragile, but he loves sitting in laps and being snuggled. He is non-ambulatory and non-verbal, but he loves listening to music. Trevor uses an overhead lift system to move and a percussion vest to help him breathe. Still, Vicie takes Trevor and his siblings out to the carnival and car races to enjoy their favorite activities. Trevor had been receiving full-time nursing care for three years. However, in July 2008, his TennCare home nursing care was unexpectedly and suddenly reduced by more than half. Taxpayers have already paid HMOs to provide Trevor the care he needs.

Frustrated but unwilling to take “no” for an answer, Vicie called TJC for help. TJC wrote a letter asking TennCare to provide Trevor the nursing care that his doctor had prescribed. Days later, Trevor’s care was reinstated and Vicie could breathe a sigh of relief. In her fight for Trevor’s care, Vicie also spoke for many other parents struggling to obtain care for their children.

Vicie also asked for TJC’s help with a TennCare policy that appeared to prevent her from leaving the house on short errands while the children were at home with their nurses. Vicie was faced with having to transport her three children, all of whom are wheelchair-bound, with her on the simplest trips to purchase groceries or to stop by the library – or not go at all. TJC wrote to TennCare about this apparent violation of the Americans with Disabilities Act. The state immediately clarified this rule so that Vicie and other parents like her are not forced to be homebound.

Vicie’s greatest hope for all children is that they can “enjoy life, live to their fullest potential, and not be held back because of disabilities.” She said it was a huge relief to have Trevor’s nursing care back, and to have the freedom to leave her home. “TJC is a lifesaver,” she said. “The folks I worked with at TJC really care about our family and will do what it takes to make sure my kids get the care they need.”