Nejuana Harris did not want to have her baby this way — rushing into an emergency room six weeks before the baby should have arrived, wondering and worrying about undiagnosed complications and unknown dangers.
"I didn't have any prenatal care," Harris said. "None."
She would have gotten that medical attention if TennCare had been in compliance with the presumptive eligibility requirement of the Affordable Care Act. Tennessee has so far failed to set up a system for hospitals to temporarily enroll patients in Medicaid who probably qualify for coverage — something hospitals were supposed to be able to do beginning Jan. 1. The delay could put state Medicaid funding in jeopardy.
"The way to fix it easily is just do what the law says," said Michele Johnson, executive director of the Tennessee Justice Center.
TennCare Director Darin Gordon acknowledges that his agency has no system for hospitals to make presumptive eligibility determinations and says his agency has prioritized complying with other parts of the federal health law.
"We have been doing our research and trying to figure out how we can implement that effectively," Gordon said. "Some would have us just throw the door open to a brand-new process, such as that, and not be as concerned about some of the controls you need to have in place."
With the full implementation of the Affordable Care Act this year, Tennessee stopped staffing hospitals with state employees who once helped pregnant women sign up for Medicaid and instead started directing them to apply at healthcare.gov or local health departments.
Denial was mistake
Harris, a Nashville mother who had already been through one high-risk pregnancy, tried to get signed up for TennCare but was denied again and again.
"I felt like they were trying to get out of paying any of my coverage," she said.
First, she had to prove to the Health Insurance Marketplace that she couldn't afford the coverage offered by her employer — that it would cost more than 9.5 percent of her annual income. After she did that, the federal insurance exchange sent notice to TennCare that she qualified for Medicaid, she said, and then she waited 45 days.
Related: Feds give Tennessee 10 days to address ACA failures
"They were supposed to approve me," Harris said. "I never got a letter yes or no or whatever after the fact."
Next she went to the Lentz Public Health Center. There, she said, "They denied me because they tried to tack on my child support with my salary."
So Harris went to Saint Thomas Midtown Hospital on May 14 to have a baby not knowing what would happen. Her last pregnancy had been complicated, with intermittent heavy bleeding.
"I was concerned about the health of the baby and myself," she said.
Finally, after her son was born and had spent time in a neonatal intensive care unit, she got a call in June from a health department employee informing her that a mistake had been made and that she actually did qualify for TennCare. The state Medicaid program covered the hospital bill.
Harris is glad her son is healthy now, but she wonders if she would have carried him longer if she had gotten access to prenatal care.
Another woman, the guardian of a baby born in January, is still worrying about a hospital bill. Sylvia Rochelle Haynes of Murfreesboro is taking care of a baby girl whose mother was incarcerated when the infant was born. The hospital was not able to make presumptive eligibility determination so Haynes started applying for coverage on the Health Insurance Marketplace.
It's complicated because the Marketplace asks for Social Security numbers — something newborns don't have. Once coverage was finally established, the start date was a month after the baby was born. So Haynes is getting billed for the child's health care from the Jan. 15 birth date until the Feb. 19 insurance eligibility date.
"I can't get no help, but I've got a bill," she said.
'People are being ping-ponged'
TennCare's reliance on the Marketplace to be the only online portal by which people can apply for Medicaid, which has multiple eligibility categories, isn't working for vulnerable people — especially babies, Johnson said.
"People are being ping-ponged between this computer system that wasn't meant to serve them, this phone line that doesn't know anything (about TennCare) and their health-care provider who would really like to treat them, but they can't," Johnson said.
But Gordon and Tracy Purcell, director of member services for TennCare, say the system is working. They point to 95,000 new enrollees since January — the largest ever since the creation of TennCare in the 1990s — as proof.
"Our main energy and focus has been on the responsibilities of helping people get eligible as they were before," Gordon said. "I think the numbers would indicate that we are having pretty good success there."
Purcell said any delays in coverage are due to factors other than Tennessee failing to provide ways for pregnant women to apply for coverage. The Health Insurance Marketplace sends lists of people eligible for TennCare daily and the agency loads them into its system nightly, she said.
"If there is a slowdown in the process, it is a slowdown that has always been there because somebody needed to send in paper verification," Purcell said.
TennCare will comply with presumptive eligibility, Gordon said, but plans to study the successes and failures of other states before moving forward. Meanwhile, the agency is working toward implementing other provisions of the law, including the rollout of a behind-schedule computer system.
Tricia Brooks, a senior fellow at the Georgetown University Health Policy Institute's Center for Children and Families, said the law is clear that states must set up a way for hospitals to transmit information to state Medicaid programs.
Other states also are behind in meeting the letter of the law on presumptive eligibility, she said.
"It is probably not the first thing that CMS is going to come down on with the states in terms of compliance with the ACA," Brooks said. "But it remains to be seen how patient will they be for how long."
Reach Tom Wilemon at 615-726-5961 and on Twitter @TomWilemon.