Eligible population. All Medicaid beneficiaries in Tennessee are enrolled in the integrated MCOs, including individuals with SMI. As of April 2013, there were approximately 1.2 million Tennesseans enrolled in TennCare, of whom 120,000 had SMI diagnoses. In one MCO (Volunteer State Health Plan), 85,000 of its 432,000 members (nearly 20 percent) were diagnosed with SMI. As of July 2013, approximately 31,974 individuals were enrolled in CHOICES; approximately 15,000 of those enrolled met the criteria for SMI (Bureau of TennCare, 2012e).
Any TennCare member is eligible for behavioral health services. Adults eligible for TennCare include participants in the state's TANF program, pregnant women, single parents or caretakers of a minor child, SSI eligibles and related groups, and individuals in institutional placements or receiving home-based services as alternatives to institutional care.
There are three groups of TennCare recipients who are eligible for the CHOICES program: (1) those who receive nursing home care; (2) those who receive home care instead of nursing home care (including adults who have physical disabilities); and (3) those who receive home care because they do not qualify for nursing home care but who are at-risk for nursing home care (including adults with disabilities) (Bureau of TennCare 2013a). To enroll in CHOICES, an individual must also qualify for Medicaid long-term care. To receive home care through the program, the cost of home care must not be more than the cost of nursing home care.
Enrollment process. Upon enrollment in TennCare, each member is matched with a PCP. All members who require behavioral health services may receive them if medically necessary. TennCare members can access behavioral health services in a number of ways. One MCO mentioned relying on the PCPs' assessment to determine whether members need case management or behavioral health services. The PCP can educate members about the appropriate provider to see. Members can also access community mental health centers or contact behavioral health providers directly. At this time, none of the MCOs requires members to obtain a PCP referral for behavioral health services. Members can seek services from any licensed or credentialed professional in the network of their TennCare MCO.
MCOs also identify members whom they want to target for more complex MCO case management. As an MCO representative explained, a member with SMI should ideally be in active mental health case management. Otherwise, the patient may disappear for a while, self-medicate, and then present at an emergency room. Rather than this type of costly and inappropriate care, the MCOs want individuals with SMI to have ongoing treatment plans. When a member accesses a community mental health center, the provider determines whether the member needs mental health case management. The MCO will monitor the case management to make sure that it is appropriate and that the services are being provided by licensed or credentialed professionals. One MCO reported that it uses available claims data to identify patients who have been discharged from inpatient care and thus may warrant additional assistance and follow-up through its discharge planning process.
Covered services. TennCare has broad benefits with no limits for treatment, except for home health and private duty nursing services for adults (Bureau of TennCare 2012b). Only licensed or credentialed providers are covered. Covered services include primary care, behavioral health, addiction and substance abuse services (services provided by methadone clinics are not covered), long-term care, home and community-based services, transportation, and supported housing and supported employment services under psychiatric rehabilitation services. The supported housing benefit offered by TennCare refers to services provided at facilities that are staffed 24 hours a day, seven days a week; there are associated mental health staff supports for priority enrollees who require treatment services and supports in a highly structured setting. The facilities are for people with SMI and are not residential treatment facilities. Supported housing is intended to prepare individuals for more independent living in the community while providing an environment that offers appropriate mental health supports, including psychosocial rehabilitation (Bureau of TennCare 2013b). TennCare does not cover room and board for supportive housing.
The key component of the CHOICES program is care coordination, which includes transition and diversion programs to support home or community-based care and which offers more consumer choices. The CHOICES program allows consumers to hire non-traditional providers such as family members, friends, or neighbors; offers more residential care choices, including family care homes; and provides improved access to assisted care facilities (Bureau of TennCare 2012c).
Care coordination. The state and MCOs are seeking to integrate physical and behavioral services and to coordinate care for TennCare members. Currently an internist is available at one behavioral health site and a few community mental health centers, and a behavioral health specialist is available weekly at certain PCP offices. To help its members navigate services, one MCO said its first line of support is customer service. The organization has an on-site call service with positive response times that helps members find a new PCP or make appointments. The call center also makes calls to patients to remind them of appointments.
Outreach efforts. Representatives from one MCO described a few of their outreach services for the SMI population, a group that the MCO perceives to be underserved. The plan sees a high percentage of elderly patients with SMI whose needs have not been addressed. Representatives attribute this problem to the generational stigma attached to mental health care. They have found that telephone outreach and postcards do not work for this population, and they have learned through community focus groups that these individuals rely on their religious community before the behavioral health community. The plan also understands that many individuals do not want to talk to someone whom they do not know. It is working on creating relationships with individuals in the CHOICES program population with care coordinators and are developing tool kits for religious leaders. Thus if someone in a congregation presents with mental health issues, the leader will have access to a list of helpful services.
Other outreach efforts by TennCare MCOs include building relationships in the community and showing providers where to direct patients if they need help with behavioral health issues. Partnering with the Tennessee chapter of the American Academy of Pediatrics, one health plan is helping to train PCPs and pediatricians in how to talk to families about behavioral health needs and how to recognize the symptoms and warning signs of behavioral health problems; it has produced a series of training videos for that purpose. Representatives of this MCO say that because people are unlikely to trust an insurance company, they are training and sharing their knowledge with members of the community who already have a trusted voice. In their view, effective outreach is hands-on and local.