Tom Wilemon

twilemon@tennessean.com

Babies who went without medical coverage, a mother of three with high blood pressure and a woman with kidney failure are among the plaintiffs in a federal lawsuit filed today contending that TennCare illegally denied them Medicaid benefits.

Three nonprofit legal firms — the Southern Poverty Law Center, the Tennessee Justice Center and the National Health Law Program — are representing the plaintiffs. TennCare has also come under fire from the federal director of Medicaid programs, who this month sent a letter putting the agency on notice that it had failed to abide by its legal obligations. The suit comes after TennCare Director Darin Gordon sent a defiant response to that letter, blaming many of the state's problems on the federal website healthcare.gov.

Lawyers for the plaintiffs said Tennessee was the worst state in the nation for fulfilling its Medicaid obligations. They are asking a judge to give the suit class-action status, which would broaden the impact of any legal decisions to other people similarly affected, and to prevent the state from refusing to process Medicaid applications within the legally required 45-day period.

"Tennessee officials are sacrificing the health of the state's most vulnerable citizens just to score political points," said Sam Brooke, staff attorney with the Southern Poverty Law Center. "They're throwing a monkey wrench into their own Medicaid program so they can demonize the federal government. People in dire need of medical care are being sacrificed."

The controversy centers around changes Tennessee began making last fall. The state ended in-person assistance for people applying directly to the state for Medicaid and sent people to healthcare.gov instead. Gordon contends that TennCare does provide in-person assistance by staffing state Department of Human Services offices with personnel specially trained to apply for coverage on healthcare.gov. But lawyers for the plaintiffs say this policy effectively "bars the door" to citizens because the federal website is not designed to process all categories of Medicaid programs in Tennessee.

Tennessee has also failed to set up a presumptive eligibility system, as stipulated by the Affordable Care Act, that would enable hospitals to temporarily enroll pregnant women and babies in Medicaid until their qualifications could be proven. Gordon did propose a correction to this problem, but asked that the temporary period be limited to 45 days.

Federal law requires that Medicaid application be processed in 45 days, but people have been forced to wait more than two or three times that long, lawyers for the plaintiffs contend. They also accuse the state of arbitrarily terminating coverage for newborns after they leave hospitals.

"It is disgraceful to see our state fall so short of its legal obligation to provide basic health care to our most vulnerable citizens, including babies who are days old," said Michele Johnson, executive director of the Tennessee Justice Center. "Tennessee is turning its back on its own citizens, and our health-care infrastructure, once the pride of our state, is becoming dismantled as a result of politics."

Many of TennCare's problems are tied to delays with bringing online a $35.7 million computer system, the Tennessee Eligibility Determination System. Gordon is hiring a consulting firm to analyze progress and problems with the computer system, which is being designed by Northrop Grumman.

Three state officials are named as defendants in the suit: Gordon, Commissioner of Finance and Administration Larry Martin and Commissioner of Human Services Raquel Hatter.

Reach Tom Wilemon at 615-726-5961 and on Twitter @TomWilemon.

The plaintiffs

The complaint, which gives only one side of a legal dispute, makes these allegations about people harmed by TennCare's policies.

April Reynolds: This mother of three from Lafayette applied for TennCare coverage in February. The next month, she suffered a high blood pressure episode and nearly had a heart attack. She was hospitalized in a critical care unit for three days.

Family of baby "S.P.": The family got billed for $17,000 after the baby was hospitalized for a bacterial infection. The family is still waiting to learn if they received coverage.

Melissa Wilson: This grandmother from Cookeville has kidney failure and is taking care of three young grandchildren. She is supposed to take 17 medications daily but can afford only three of them. She has called TennCare every two weeks since February and has been told each time that the status of her application is not known.

Baby "S.G.": This infant who lives in Madison was born two months premature and was born into CoverKids coverage, but the state revoked this Medicaid plan for the baby when he left the hospital, and he has been without coverage since. He needs monthly shots costing $3,000 each to prevent a potentially fatal respiratory virus, but his parents cannot afford the treatments.

Mohammed Mossa and Mayan Said: This married couple from Antioch have severe health problems and take care of five minor children. He has leukemia and also suffers from a back injury. She has diabetes, anemia, high blood pressure and kidney stones. They applied for TennCare in February but cannot get answers regarding the status of their application.

Mother "T.V" and baby "K.P.": This expectant mother from Soddy-Daisy applied for coverage in late January and gave birth in April. In numerous calls to Tennessee Health Connection — the state-run call center for people to check on the status of applications — this mother has been told her application was not in the system. She most recently contacted the call center the week of July 14 and was told again the application was not in the system. She asked if she could have a hearing and was then told the application had already been escalated and that she could not receive a hearing.

Father D.A. and baby C.A.: This Nashville father of a newborn son applied for coverage on healthcare.gov. Federal employees told him the application was complete and to check with the state-run Tennessee Health Connection about enrollment. When the family contacted Tennessee Health Connection, they were told there was no record of the account.

Baby "S.V.": This Nashville infant was born in January. His mother applied for TennCare in January but did not receive a response. In May, she applied again. She called Tennessee Health Connection numerous times but staff members told her they could not find information about the status of the application. When the mother called the week of July 14, she was told her child still did not have coverage. She requested a hearing and was told she could not get one because she had not been denied.

TennCare failures

• Ability to accept a single, streamlined application

• Ability to convert state income standards to new federal standards

• Ability to convey Tennessee eligibility rules to the Health Insurance Marketplace, the federal exchange

• Ability to process applications on new income rules

• Ability to respond to inquiries from the Health Insurance Marketplace about applicants' current Medicaid coverage

• Ability to verify eligibility based upon electronic data services

— Cindy Mann, federal director of Medicaid services