SPLC lawsuit challenging Tennessee Medicaid application delays goes to trial

In 2014, Don Adams put off going to the hospital for treatment of an infection after the state of Tennessee failed to promptly decide on his application to TennCare, the state’s federally funded Medicaid program.

When he finally went to the emergency room, he learned that he was infected with MRSA – a type of bacteria that is highly resistant to antibiotics – and that if he had waited a few hours longer, he would have died.

Earlier that year, Adams’ wife gave birth to their son, but the parents struggled with how to pay for his pediatric visits and immunizations. The initial pediatric visit resulted in a $1,300 bill they could not pay. When they tried to schedule another visit, the doctor’s office told them they could not return until they showed proof of insurance. 

Adams’ story is an example of the thousands of eligible Medicaid applicants in Tennessee who have been forced to wait unlawfully long periods of time for their applications to be processed. He and his son are plaintiffs in a class action lawsuit filed by the SPLC that goes to trial today.

It describes how such long delays have forced eligible Medicaid applicants to go without vital health coverage, or to rack up monthly medical bills they cannot afford. The SPLC and its partners filed the lawsuit in July 2014 on behalf of a class represented by 11 named plaintiffs who have faced life-threatening conditions while awaiting a decision on their application from TennCare.

The lawsuit, which goes to trial in the U.S. District Court for the Middle District of Tennessee, describes a series of administrative decisions by state officials that have led to unnecessary bureaucratic delays. The delays include a requirement that applicants go through the federal Health Insurance Marketplace website, healthcare.gov, which was not designed for that purpose and does not screen for all eligibility categories.

“It has been four years since we filed the lawsuit, and thousands of Tennesseans who are eligible for TennCare continue to have their rights to a prompt decision violated,” said Sam Brooke, deputy legal director for the SPLC. “By requiring people who qualify for Medicaid under state and federal law to jump through a series of unnecessary bureaucratic hoops, the state is depriving thousands of low-income citizens of timely access to essential medical care. We are asking the court to require Tennessee to finally fix this broken system.”

Shortly after the lawsuit was filed, a federal judge granted a preliminary injunction that required TennCare officials to hold a fair hearing within 45 days for people whose Medicaid applications were unreasonably delayed. The applicants, however, must request the hearing to have the application problems resolved.

Moreover, the preliminary injunction does not require the state to identify and correct the problems that caused the delays. As a result, the delays have continued. Since May 2015, more than 21,000 applicants have requested such hearings after the state failed to respond to their application within the 45-day requirement under federal law. Some have waited as long as 90 days.

The federal Medicaid Act, which governs the TennCare program, states “that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals.”

Federal regulations require that a determination for eligibility take no longer than 45 days, unless the basis for eligibility is a disability.

The trial will take place before U.S District Court Judge William L. Campbell Jr.

The Tennessee Justice Center (TJC) and the National Health Law Program (NHeLP) joined the SPLC in filing the lawsuit.

For more information, view our case docket.