Cost and Coverage of Medicaid in Tennessee

Obtaining Tennessee Medicaid coverage is just the beginning for applicants who have just received their benefits. The next question a beneficiary may ask his or her self is, “What are Medicaid cost estimates?” and a logical follow-up question would be, “What services are covered by Medicaid?” The answers to these questions are varied and are based upon the type of service rendered as well as the type of plan a beneficiary has. TennCare uses a managed care Medicaid coverage model to deliver benefits to patients. Enrollees will need to choose a primary managed care organization for the most common medical needs and a choose additional plans based upon other needs they may have such as dental, pharmacy and mental health services. The organization sets prices for co-pays and deductibles. In the following sections, you will find answers to those questions about the types of Medicaid insurance and much more.

For information about Medicaid coverage in Tennessee, consult the respective section:

  • What services are covered by Medicaid in Tennessee?

  • What does Medicaid not cover in Tennessee?

  • How much does Medicaid cost in Tennessee?

What services are covered by Medicaid in Tennessee?

Tennessee Medicaid cost estimates will differ depending on the beneficiary and the type of service they seek. Some medical services are offered free of charge while others involve some sort of co-payment. Pregnant women, however, only need to ask themselves “what does Medicaid not cover,” as routine pre-natal services are offered free of charge.

To figure out how much does Medicaid cost, determine which group you fall into. As previously mentioned, pregnant women receive medical care free of charge including up to the day the child is born. Children younger than 21 years of age are covered for free as well. For the most part, TN Medicaid costs estimates are the same for the majority of beneficiaries, with preventive services being free of charge across the board.

No co-payment is required for the following services:

  • Annual check-ups

  • Vaccinations

  • Pap smears

  • Mammograms

  • Prostate examinations

The above mentioned list does not fully encapsulate what services are covered by TN Medicare, as many other benefits are offered for a small co-pay. Other services covered by TennCare include hospice care, lab and X-ray services and emergency services, among others. The type of Medicaid insurance coverage a beneficiary has is dependent upon the options of their plan benefits package. The best way to know if a service is covered under your plan is to refer to your benefits package materials provided by your managed care organization.

What does Medicaid not cover in Tennessee?

While Medicaid coverage in Tennessee is available at little to no cost for most TennCare beneficiaries, a few services are not covered by their plan and must be paid for through another type of Medicaid insurance — such as dental insurance — or paid for out-of-pocket. To determine what services are covered by Medicaid for your particular plan, refer to your benefits guide.

Though, generally TennCare does not cover services that are not deemed medically necessary. For information on what does TN Medicaid not cover, refer to the list that follows:

  • Chiropractic services

  • Dental services (excluding those for children and adults younger than 21 years of age)

  • Regular vision exams and lens prescriptions

Medicaid cost estimates are very important to beneficiaries when it comes to service that are not defined as medically necessary. Petitioners should be aware of the medical treatments that will incur added costs should they need to solicit them. For example, private duty nursing services are covered for adults 21 years of age and older only in cases where life-sustaining medical technology is utilized. Also, with all types of Tennessee Medicaid insurance plans, vision services that are not due to the evaluation and management of an abnormal eye condition, are not covered. Beneficiaries will need to secure supplemental insurance in these areas.

How much does Medicaid cost in Tennessee?

Determining how much is Medicaid going to cost you is largely reliant upon your income. Beneficiaries with very low income are not required to pay a monthly plan premium. However, those that do not fall into that category will have higher Medicaid cost estimates as they are presumed to be able to afford them. Families should feel some sense of security in knowing that federal guidelines prohibit them from spending more than five percent of their annual household income on out-of-pocket medical expense.

Many TN Medicaid coverage benefits are offered free of charge to certain covered groups such as pregnant women, children younger than 21 years of age, women being treated for breast and cervical cancer and other populations that fall below 138% of the poverty line. However, a doctor’s visit co-payment ranging from $10 to $30 or more may be necessary if your income is above the threshold of what is considered ‘very low income.’ Through their managed care organization, a beneficiary would arrange medical services, therefore, how much is Medicaid service will be largely depending upon the prices offered through that particular provider.

While most Tennessee residents are covered by some type of Medicaid insurance — whether it be through TennCare or through the health insurance marketplace — others do not. Single adults with no dependents who earn less than the Federal Poverty Level do not necessarily qualify for coverage through TennCare. In that case, he or she must visit the health insurance marketplace, made available through the Affordable Care Act (ACA), to find a plan that fits the designated income range. Medicaid cost estimates for such a benefits applicant, is comparable to the average cost of employer-sponsored coverage in the region. Annually, Tennesseans between 100% and 138% of poverty pay around $1,100 in Medicaid-subsidized premiums through the marketplace.



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