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.