TennCare Select vs TennCare PHP

Hello, I am hoping someone here can tell me the difference between TennCare Select vs TennCare PHP? I also would love to know why TennCare Select will pay for a lap band or the Y but not DS. When reading the many obesity sites I have read several times about those who are undergoing or have already had a revision. The the Y surgery is now being changed to the DS. As a woman in pre-menapause I believe, and it is only my thougths, the more I can keep of my own stomach the better off I will be. Should you have any information that you believe that would help me, let me thank you now. God Bless

Hi Debra! I really can't tell you the difference - However, I do have TNCare Select but the last I heard they don't pay for lap banding. Have you talked to the insurance company to be sure about that? I'm not trying to cause any trouble -- Just thought I'd share what I knew! Hugs, Katie

Hi Katie, I am told Dr. Steely's partner (Clarksville), a woman, is doing lap bands and the Y. She accepts TennCare Select, I know this because one of my PCP's office girls is getting the band using her TennCare Select. If TennCare Select will pay for the Y and band (even if not both) which are both weight loss surgeries then there is no reason that I can't have the DS. I feel it borders on discimantion that I have to have a surgery (Y)that has more revision each year than just having the DS to start with. I don't want to lose all my stomach, as a woman in pre-menapause, I need the valves there to help with absorption of calcium and other vitamins. It is my body and I should have the choice of what I think is best for me. Oh, and my PCP agrees! Good Luck! I am getting the DS and Dr. Husted's office will be doing it. Even if I have to go to the highest courts. Debra

I am seeing the surgeon that is in the same office as Dr. Steeley. She is not in practice with him though and she will make that very clear (even though he is her assist on the surgery) she does not do lap band only RNY but she does do laporscopic surgery but Im not sure if she does RNY that way she is going to be preforming an open RNY on me. Also from what my case manager has told me most TNCare MCO's have stopped covering the lapband and DS because they feel that both of those are still too experimental.

I am betting you have the right doctor. I have never met her but here good things. I wish you much luck and prayers with your surgery. I do have to say that the DS has been around for 12 years. I believe it is way past experimental and I am willing to bet my life on it. Also, ask your doctor if something goes wrong with the RNY what surgery they recommend. I am being told that would be the DS as a revision. I find it pretty strange that if you live on the East side of the state and have TennCare PHP you can have the DS BUT if you live on the West side and have TennCare Select.............too bad. TennCare Select will only pay for the DS when it is a revision. AND both programs are Medicaid! Does anyone else have a problem with this?

Both programs are Medicaid, however they are managed by two different insurance companies. PHP is managed by Cariten and Select is managed by Blue Cross Blue Shield of TN. Different companies have different policies, as long as they don't conflict with Medicaid/Tenncare's policies.

Be that as it may, Tennessee is one state. To get Medicaid you must be "way below average" in income, to put it nicely. I am saying it is NOT ok for half the state to have one kind of medicaid while the other has something completely different when it comes to coverage in certain medical areas? I want the DS surgery. Because I live on the west side of the state, Medicaid says no. BUT if I live on the other side of the state it would be ok! Hey, no one asked me which company I wanted to have or that there was even any kind of difference depending on where we lived. I wonder how many people this happens to in the state of Tennessee? Vanderbilt is here on the west side, does that mean the children and adults who need cancer treatment can't get it because they live on the other side of the state? We moved here from Florida to Tennessee 18 months ago because my husband had just had his tongue removed because of cancer. The surgeon who did the surgery was leaving to another hositpal and recommend Tennessee as it "would be where I would go"...... meaning Vanderbilt. At no time did anyone, the real estate person, the social worker, or the new PCP, not one person, ever told us there was a difference in coverage depending on which side of the state one lives. I need this surgery to live. And where IS the line? Maybe I should think about "moving" until I get the surgery. Bottom line here for me is this: It shouldn't matter where ones lives in Tennessee............IF you have medicaid, the "Policies" should be the same across the state or we should be given a choice.

A LITTLE SOMETHING I THOUGHT I WOULD SHARE: "The TennCare model has been revised in the past year. The model now focuses on regional, rather than statewide, MCOs, and it sets a target of no more than 300,000 members per MCO. A major reconfiguring of health plans across the state is underway. There will be two new MCOs involved in TennCare, Better Health Plans in the West and Universal Care in the Middle Tennessee Region. BlueCare, which has been in all three regions, will be offered only in East Tennessee. Access MedPlus will be available in all three regions as long as it does not exceed the state's enrollment limits. OmniCare will no longer be available in Nashville, but it will be available in all of West Tennessee. Xantus is moving out of East and West Tennessee, but it will continue to available in Middle Tennessee." SOURCE:http://www.state.tn.us/tenncare/SelectFAQs.html AND THIS: TennCare Select "TennCare Select" is Tennessee's self-insured TennCare health maintenance organization (HMO) that will be available for certain TennCare enrollees on July 1, 2001. TennCare Select will be administered by Blue Cross/Blue Shield of Tennessee under the direction of the TennCare Bureau. Behavioral health services will be provided for TennCare Select enrollees through a TennCare Partners behavioral health organization (BHO) just as they are for all other TennCare enrollees. The two basic purposes of TennCare Select are: (1) to provide services to populations who are more difficult to serve because of their health care needs, their mobility, and/or their geographic location; and (2) to serve as a "back up" in any area of the state where TennCare enrollees cannot be adequately served by the other TennCare HMOs. The TennCare Bureau has identified the groups of enrollees who may become members of TennCare Select; individuals cannot request TennCare Select independently. The groups that have been identified, in addition to any resulting from a "back up" enrollment include the following: Children whose eligibility category is SSI; Children who are in the custody of the state; Children who are in an institutional eligibility category (whi*****ludes children in the Home and Community Based Services waiver for individuals with mental retardation); Enrollees whose residences are out-of-state; Enrollees who have been identified as being "potentially ineligible"-that is, Uninsured and Uninsurable enrollees who have not responded to reverification activities and whose family members have not used TennCare services for a set period of time. These enrollees have not yet been dropped from TennCare enrollment, pending implementation of a recent court settlement. Enrollees in all of the above groups, except for those in the out-of-state group, can choose to be in other MCOs if they do not want to be in TennCare Select. SOURCE:http://www.state.tn.us/tenncare/TennCareSelect.html Hope it helps, it did me! Thank you all for your information

Actually you can request which plan you wish to be on sort of. For instance I was on TNCare select then they took it among themselves to move me to PHP. MY PCP didn't take that, my CNM nor any of the pharmacies I had been going to. So I called to get changed back to Select or to be put on BlueCare. They informed me that since it was past the time for me to vote on a MCO that I would have to put in an appeal. So I did and of course they denied it so I did as the paper said I requested a hearing before an admistration court. TNcare called me several times to see if I really wanted to do that and I stuck to my guns on it. Explained to them that them changing my MCO totally changed my medical care. A dr I had been seeing since I was 16 not to mention how hard it is to get a GYN with the TNcare plan unless you are pregnant (which I have no intentions of becoming anytime soon). So a hearing was scheduled first they wanted to do it by phone since "it was going to be several months before I could be actually before the judge" I told them no I want my day before the judge so they rescheduled. Two weeks before the date I got a BlueCare card in the mail and a letter stating that my MCO had been changed per my request. of course that week TNcare called to see if I still wanted the hearing. I told them there was no need now. They put the judge on the phone and he asked me if I was wanting to take my case of the docket I told him yes and that has been the end of it. Now I know that TNCare select is a "special" program but BlueCare is also run by Blue Cross as Select is and pretty much has similar benefits as it.Im just happy that I was able to keep my same Drs I hate having to find new ones.

Thank you Augusta, I will be calling the TennCare office today. I am in the middle of writing the Governer to ask him the some questions. Let you know what happens.