Jonathan Reeve From: Sent: To: Subject: Attachments: Feroza Freeland Friday, October 18, 2019 3:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] A Better Balance Comment on Amendment 42 ABB Comment_Medicaid Block Grant Proposal_Submitted 10-18-19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Roberts,    Please find attached a comment from A Better Balance: The Work & Family Legal Center regarding proposed Waiver  Amendment 42.    Thank you,     Feroza Freeland  Policy Associate    A Better Balance: The Work & Family Legal Center 2301 21st Avenue South, Suite 355 Nashville, TN 37212 Office: 615-915-2417 Follow Us: www.abetterbalance.org I Facebook I Twitter I Instagram 1 the work and family legal center 2301 21st Ave. South, Suite 355, Nashville, TN 37212 I t: 615.915 .2417 I info@abetterbalance.org I abetterbalance.org Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 via email to: public.notice.tenncare@tn.gov RE: TennCare Waiver Amendment 42 Dear Mr. Roberts, A Better Balance writes in response to the public notice inviting public comments on proposed Waiver Amendment 42. A Better Balance (ABB) is a legal advocacy organization with an office in Nashville dedicated to promoting fairness in the workplace. Our mission is to promote equality and expand choices for individuals at all income levels so they may care for themselves and their families without sacrificing their economic security. We employ a range of legal strategies to promote flexible workplace policies, end discrimination against caregivers, and value the work of caring for families. Our free and confidential legal helpline receives calls from low-wage workers across the state, who often rely on Medicaid for healthcare. Our organization is unequivocally opposed to this proposal that would radically change Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans, including many of our clients. ABB is particularly concerned about the impact that this proposal would have on pregnant women, people with children or other caregiving responsibilities, and those with chronic health conditions, all of whom make up a significant portion of our client population. Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable individuals access vital health coverage. This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these vulnerable 1 the work and family legal center 2301 21st Ave. South, Suite 355, Nashville, TN 37212 I t: 615.915 .2417 I info@abetterbalance.org I abetterbalance.org populations. Under this proposal, the state could eliminate or restrict services like physical therapy, hospice, and transplant coverage without normal federal oversight, or arbitrarily limit who gets them. The proposal could also cut back on core health care services, like hospital care, without federal approval or public notice, and exclude coverage of the most effective prescription drugs. Furthermore, this proposal may actually incentivize the state to cut services and reduce enrollment in the TennCare program. According to one analysis, the proposal would “nearly double the state’s financial reward for cutting Medicaid spending on children, low-income parents, and people with disabilities, whether by shrinking enrollment or by cutting services.”1 TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid program without federal oversight, nor should it have the authority to eliminate federal standards, which are in place for the protection of patients. Without such guardrails, the state could return to the days when managed care contractors failed to provide care to patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans. This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program, which is intended to serve as a vital safety net for vulnerable lowincome citizens. Undermining this safety net would be contrary to the best interests of all Tennesseans. We therefore respectfully urge you not to go forward with this harmful proposal. Sincerely, A Better Balance 1 Hannah Katch, Judith Solomon, and Aviva Aron-Dine, Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, Center on Budget and Policy Priorities, (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grant-proposal-threatens-care-for-medicaid-beneficiaries. 2 Jonathan Reeve From: Sent: To: Subject: Attachments: Abby Emanuelson Friday, October 18, 2019 11:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] FW: National MS Society TennCare Public Comments TN Block Grant - NMSSComments.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Attached please find the National MS Society’s comments regarding the TennCare II Demonstration Amendment 42  (Project No. 11‐W‐00151/4).      Abby Carter Emanuelson AVP, Advocacy and Activist Engagement    National Multiple Sclerosis Society  Tel  +  800.344.4867, 2, ext. 15975  Dir  +  303.698.8775  Cell + 919.389.3553           JOIN THE MOVEMENT  www.nationalMSsociety.org        1 October 18, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: The National Multiple Sclerosis Society (Society) appreciates the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4). The Society opposes Project No. 11-W-00151/4 as currently proposed. Nearly one million people are living with multiple sclerosis (MS) in the United States, more than twice the original estimate. MS is an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body. Symptoms vary from person to person and range from numbness and tingling, to walking difficulties, fatigue, dizziness, pain, depression, blindness and paralysis. The progress, severity and specific symptoms of MS in any one person cannot yet be predicted but advances in research and treatment are leading to better understanding and moving us closer to a world free of MS. The Society is committed to ensuring that TennCare provides quality and affordable healthcare coverage. Unfortunately, this proposal to convert the funding structure of the TennCare program to a block grant will jeopardize beneficiaries’ access to care. Specifically, its structure, prescription drug benefit plan and lack of an appeal process, flexibilities that reduce federal oversight and access to providers and benefits, fiscal sustainability and lack of Medicaid expansion are why the Society opposes TennCare II Demonstration Amendment 42. Block Grant Structure The Society opposes Tennessee’s proposal to change the financing structure for its Medicaid program to a block grant. We fear that the state will cut coverage for certain treatments completely or impose additional barriers to important services, making it more difficult for patients to access the care that they need. For people with MS, access to needed health care services and early and consistent control of disease activity plays a key role in preventing accumulation of disability and allows people with MS to remain active in their communities. Adding barriers and complicated administrative processes will result in people with MS losing - not gaining - health care. Additionally, Tennessee may choose to cut payments to providers to help keep spending under the new block grant. As the gap between the block grant and actual costs of care increases over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients will only increase. Even small cost-sharing amounts may be substantial for a low-income person or family, potentially making coverage unaffordable for those who need it most. These cuts would be unacceptable. This structure will not protect either the state or beneficiaries from financial risk. The per capita adjustments to the block grant will not be sufficient. For example, there are many ground-breaking treatments in development for patients with serious and chronic illnesses. If an expensive but highly effective treatment became available, Tennessee’s spending could rise, putting the state’s budget at risk and creating an incentive for the state to impose additional barriers for that treatment. Tennessee’s proposal would include vulnerable eligibility groups such as children and people with disabilities in the block grant. We have serious concerns about how this will impact their care. Additionally, under this proposal, current and future administrations would not need to get approval to make changes to benefits and services, putting these patients’ care at grave risk. We join many consumer advocates that are confident changing TennCare to a block grant through the 1115 waiver process is illegal. The Secretary of Health and Human Services is not permitted to waive Sections 1903 and 1905, where the financing structure of the Medicaid program is located, through these types of waivers, as multiple experts have noted.1,2 Such a change would require congressional authority, yet Congress has repeatedly declined to pass legislation on this issue, most recently during the debate over repealing and replacing the Affordable Care Act in 2017. Prescription Drug Benefit Plan The Society opposes the proposal to create a closed formulary with as few as one drug per class and exclude prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated approval process. Limiting access to medications with different mechanisms of action will be detrimental to people living with MS as a growing body of evidence indicates that early and ongoing treatment with an approved Disease Modifying Therapy (DMT) is the best way to manage the MS disease course, prevent accumulation of disability and protect the brain from damage due to MS. Restricting TennCare’s drug benefits to a closed formulary would limit the ability of providers to make the best medical decisions for the care of their patients, effectively taking the clinical care decisions away from the doctor and patient and giving them to the state. No single agent is ‘best’ for all people living with MS. As MS presents differently in each individual, every person’s response to a DMT will vary and these treatments are not interchangeable. It is not uncommon for people to work their way through several of the medications as they find the one that stabilizes their disease. In addition, a medication that adequately controls MS progression now may not do so in the future and people living with MS may need to change to a different medication. Fortunately, today there are nearly twenty effective therapies that are FDA approved. In the last two years we have seen approval for treatments for secondary progressive MS, the first and only medication for primary progressive MS, and one medicationfor use in children age 10 and older. Allowing TennCare to exclude prescription drugs approved through FDA’s accelerated processes will harm patients by restricting access to novel and lifesaving therapies. The waiver proposal also does not include an appeals process for patients to access prescription drugs that are no longer covered. TennCare patients include very low-income pregnant women, the elderly, children and the blind and disabled. These individuals rely on Medicaid to provide treatment and may need access to a medication no longer covered under the new restrictions. Without an appeals process to access denied medications, these patients could experience worse health outcomes and even death. State Flexibilities The Society opposes a number of proposals in the waiver application considered under the broad moniker of “state flexibilities.” The Society is concerned that “flexing” the federal standards and requirements for Tennessee’s managed care program would jeopardize important safeguards that Medicaid Managed Care Organizations (MCOs) have to meet related to patient care and network adequacy. For example, the managed care rule sets standards related to adequate networks, so patients can actually see the appropriate providers and receive the care they need. The managed care rule requires MCOs to comply with standards of time and distance to measure this network adequacy, helping patients access both primary care providers and specialists they need. Network inadequacy raises particular concerns for people living with MS and others with specialized and complex healthcare needs. People living with MS may require care from neurology, rehabilitation, radiology, mental health and other specialists, as well as treatments, services and products from pharmacies, durable medical equipment providers, home care agencies and more to live their best lives. In addition, requesting to change the “amount, duration, and scope” of benefits would allow Tennessee to put caps on services or only cover critical services for certain individuals. The Medicaid population, by definition, is a vulnerable population, this change could negatively impact patient care and outcomes. Access to affordable, quality health care is vital for all of us, but especially for people living with MS. Accessing consistent treatment can reduce the number of new lesions and exacerbations, slow progression of disability, and may reduce future disease activity. Benefit package design must address the health needs of people living with MS. We have significant concerns that arbitrary caps on services or benefits will prevent people living with MS from seeking necessary treatment, which then may become more difficult and costly to treat or lead to more expensive emergency care. Finally, the state would no longer need to get approval to make changes to benefits and services in the future and would like to make this demonstration permanent, removing important opportunities for the public to provide feedback on the how the program is working for key stakeholders before any policies are implemented or continued. It is especially important that beneficiaries impacted by the demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint venture between Tennessee and CMS. Both entities, as well as the people it serves, should have a voice in how the program is administered. Fiscal Sustainability If Tennessee is truly concerned about the fiscal sustainability of its Medicaid program, the state could submit a state plan amendment to fully expand Medicaid to 138 percent of the federal poverty level and receive a 90 percent match from the federal government for all expenses for the adult expansion population. This policy would both benefit the state financially and extend access to care to more lowincome individuals in need of coverage, a core objective of the Medicaid program. Tennessee has also failed to provide a complete budget neutrality estimate with details of the projected changes in spending with the waiver and any impact on coverage. The federal rules at 431.408 pertaining to state public comment process require at (a)(1)(i)(C) that a state include an estimate of the expected increase or decrease in annual enrollment and expenditures if applicable. The intent of this section of the regulations is to allow the public to comment on a Section 1115 proposal with adequate information to assess its impact. Given that this waiver represents a fundamental change to Tennessee’s demonstration, the state should include these projections and their impact on budget neutrality provisions. The core objective of the Medicaid program is to furnish healthcare to low-income and needy populations. This waiver does not further that goal and the Society opposes the proposal. Thank you for the opportunity to submit comments. Sincerely, Abby Carter Emanuelson AVP, Advocacy and Activist Engagement 1 Joan Alker. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown University Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/ pending-cms-guidance-on-medicaid-block-grants-executive-overreach-strikes-again/. 2 https://theincidentaleconomist.com/wordpress/tennessee-wants-to-block-grant-medicaid-is-that-legal/ Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Alisa LaPolt Friday, October 18, 2019 10:32 AM PUBLICE NOTICE TENNCARE Jeff Fladen [EXTERNAL] TennCare Block Grant comments from NAMI Tennessee NAMI Tennessee_TN 1115 Medicaid waiver comments.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please find attached comments from NAMI Tennessee regarding the proposed TennCare block grant waiver.  This document reflects a great deal of thought and input from our organization on the state and national  levels.    We appreciate the opportunity to provide input on this very important topic.    Regards,    Alisa LaPolt  Director of Policy and Advocacy  NAMI Tennessee  1101 Kermit Dr., Suite 605  Nashville, TN 37217  Office 615‐361‐6608, Cell 850‐443‐1319         1 October 18, 2019 Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: 1115 Waiver Amendment 42 to the TennCare II Demonstration Dear Director Roberts: NAMI Tennessee, the state chapter of the National Alliance on Mental Illness, appreciates the opportunity to submit comments on Tennessee’s 1115 Waiver Amendment, “Notice of Change in TennCare II Demonstration: Amendment 42.” NAMI is the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. Access to coverage and care is essential for people with mental illness to successfully manage their condition and get on a path of recovery. Medicaid is the lifeline for much of that care, as the nation’s largest payer of behavioral health services,i which provides health coverage to 27 percent of adults with a serious mental illness.ii Under Amendment 42, the state proposes to “block grant” TennCare, which currently has an open-ended funding structure shared by the state and federal government. NAMI Tennessee is very concerned that a block grant will jeopardize access to care and have harmful implications for the 1.4 million TennCare beneficiaries, including those with mental health conditions. Therefore, NAMI Tennessee strongly urges the Division of TennCare to withdraw this proposal. TennCare Eligibility and Coverage Under Amendment 42, nearly all TennCare beneficiaries – including children, parents with low incomes, and people with disabilities – will be subject a new system that has considerable authority and discretion over their eligibility and benefits. In the event that the block grant funding is less than what the state needs – especially for unanticipated costs like economic recessions, epidemics, or medical breakthroughs – enrollment, eligibility, benefits and provider payments will have to be on the line. While the proposal claims that no changes will be made to current services or covered populations, NAMI Tennessee finds it concerning that the state is explicitly seeking authority to make such changes in the future without federal approval as a part of its request. This is particularly concerning to NAMI Tennessee as it could mean that Medicaid coverage for people with mental illness could be in jeopardy at the whim of the state. We are also concerned over how the proposed “savings” will impact beneficiaries. Under the proposal, Tennessee would receive 50 percent of every unspent dollar from the TennCare program, with the remainder going to the federal government. It is difficult to see how any savings could be achieved without changes to eligibility, services, or provider payments. Given the state’s strong financial incentives – and new authority – to cut benefits, reduce enrollment, or slash provider payments, NAMI Tennessee worries how this will impact access to critical mental health services like therapy, inpatient stays, or medication management. This is troublesome, as many mental health providers like psychiatrists already accept fewer Medicaid patients than physicians overall.iii The additional authority would also grant the state the ability to make it more challenging to enroll or re-enroll in coverage, such as when the state imposed new procedures that resulted in nearly 130,000 children losing coverage.iv Altogether, NAMI Tennessee worries that such changes will result in reduced access and coverage for people with mental health conditions. We know that for these beneficiaries, losing Medicaid coverage leads to prolonged reductions in critical mental health services and supports,v often causing the severity of their condition to increase. Sadly, we know what happens when people with a mental illness don’t get treatment; they end up in hospital emergency rooms, in jail, or on the streets with worse long-term outcomes and at greater cost to the state and the federal government. We strongly request that the state withdraw this portion of the proposal. Prescription Drugs NAMI is also concerned about how Amendment 42 will impact prescription drug coverage. While the proposal carves out prescription drugs from the TennCare demonstration, it still calls for largescale changes that have yet to be approved in other states. Specifically, the state has proposed a “closed formulary” which would allow the state to exclude certain drugs from the prescription benefit. The result of such a change would mean that Tennessee has the authority to deny TennCare beneficiaries access to FDA-approved prescription drugs. At minimum, TennCare would only be required to cover one drug per therapeutic class. Drugs could be added to the formulary when “market prices are consistent with prudent fiscal administration” or “sufficient data exist regarding the cost effectiveness of the drug.” This request is troublesome for several reasons. The state argues that such a practice is necessary to “avoid exorbitant spending on high-cost drugs that are not medically necessary, which do not provide additional clinical benefit, and/or which actually pose health risks for members when prescribed without sufficient medical evidence.” However, such broad authority to determine medical necessity and clinical benefit could create a “one size fits all” approach that fails to consider beneficiaries’ unique situations. People with mental health conditions respond differently to the same drug based on a variety of factors – meaning that what works for one individual may not for another. Yet under this proposal, someone taking medication for bipolar disorder could lose access to the medication that works best for them (and as we know, often after much trial and error), simply because the state has chosen not to include it on the formulary. The proposal also fails to recognize the important trade-offs that many people with mental illness make in consultation with their health care providers. For example, most psychotropic medications, particularly antipsychotic medications, can cause weight gain, obesity and type 2 diabetes.vi Beneficiaries should be able to make choices about their medications – rather than be forced into a drug because it is the only medication on a formulary, or lose access to a drug because of a perceived lack of necessity or clinical benefit. We strongly request that the state withdraw this aspect of the proposal. Oversight, Consumer Protections and Appeals This proposal would remove federal oversight over the amount, duration, and scope of services provided to individuals enrolled in TennCare. NAMI Tennessee is concerned about the proposal’s overall lack of federal oversight, consumer protections and appeals processes. If TennCare beneficiaries are denied critical prescription medications or have their coverage wrongly terminated, they will have little option under Amendment 42, further jeopardizing their course of treatment and wellness. We strongly request that the state withdraw this aspect of this proposal. Contradictory Nature of Proposal Lastly, NAMI Tennessee would like to point out the contradictory nature of the proposal, in matters such as financing, exemptions, and flexibility. Under the proposal, the annual block grant payment would be adjusted upward if enrollment grows past baseline calculation. No adjustment would be made if enrollment falls. Moreover, the proposal also carves out certain expenses, including prescription drugs, uncompensated care payments to hospitals, services provided to members enrolled in Medicare, and administrative expenses. While we’re glad to see attention paid to enrollment trends and critical TennCare components, it ultimately calls into question the necessity of Amendment 42 if the state does not feel fully confident in a Medicaid block grant model. A similar point can be made regarding the state’s argument for additional flexibility. According to the proposal, Amendment 42 will allow the state to “implement new reform strategies that would reap benefits for both the State and the federal government.” However, Tennessee already has the ability to exercise flexibility in the TennCare program without resorting to troublesome funding structures and reduced accountability. For example, the state could create an 1115 waiver for the Institutions for Mental Diseases (IMD) exclusion for Serious Mental Illness to provide more treatment options to people with mental illness. Additionally, the state could expand the Medicaid program to address Tennessee’s coverage gap, which has led to improvements in access to medications and services for the treatment of behavioral conditions in other states.vii The state could also invest in evidence-based supported employment programs, which have proven effective in helping vulnerable populations, such as people with mental illness, recover and return to work.viii Unnecessary Risks for People with Mental Health Conditions NAMI Tennessee appreciates the state’s efforts to innovate and better manage health care costs; however, we are concerned that the proposal greatly compromises TennCare’s ability to meet the need for mental health and substance use disorder services in the future. Moreover, we believe that implementing a block grant will take Tennessee backwards without furthering the goals of the Medicaid program. The goal of the Medicaid program is to provide health coverage to those without access to care, not to arbitrarily cut benefits to remain within arbitrarily set block grant. NAMI Tennessee urges Tennessee to withdraw this proposal in its entirety. The proposal will not promote beneficiary care and will likely harm people with mental health conditions. We encourage the department to focus on other solutions under existing authority that meet the intent of the demonstration proposal without the adverse consequences presented by a block grant. Thank you for the opportunity to provide comments. Sincerely, Jeff Fladen, Executive Director NAMI Tennessee 1101 Kermit Dr # 605 Nashville, TN 37217 Alisa LaPolt, Director of Policy & Advocacy i Medicaid and CHIP Payment and Access Commission, “Behavioral Health in the Medicaid Program―People, Use, and Expenditures,” June 2015, https://www.macpac.gov/publication/behavioral-health-in-the-medicaid-program %E2%80%95people-use-and-expenditures/. ii Rebecca Ahrnsbrak, Jonaki Bose, Sarra Hedden, Rachel N. Lipari, and Eunice Park-Lee, “Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health,” Substance Abuse and Mental Health Services Administration, September 2017, https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUHFFR1-2016.pdf. iii Kayla Holgash and Martha Heberlein, “Physician Acceptance of New Medicaid Patients,” Medicaid and CHIP Payment and Access Commission, January 2019, https://www.macpac.gov/wp-content/uploads/2019/01/Physician-Acceptance-of-NewMedicaid-Patients.pdf. iv Brett Kelman, “Tennessee erased insurance for at least 128,000 kids. Many parents don’t know,” Nashville Tennessean, April 1, 2019, https://www.tennessean.com/story/news/health/2019/04/02/tennessee-tenncare-coverkids-medicaid-erased-healthcare-coverage-for-children/3245116002/. vXu Ji et al. Effet of Medicaid Disenrollment on Health Care Utilization Among Adults with Mental Health Disorders. Medical Care, August 2019, vol. 57, no. 8, p. 574-583. DOI: 10.1097/MLR.0000000000001153. vi J Muench and AM Hamer. Adverse Effects of Antipsychotic Medications. American Family Physician, March 2010, vol. 81, no. 5, p. 617-622. https://www.aafp.org/afp/2010/0301/p617.html. vii Larisa Antonisse et al., “The Effects of Medicaid Expansion Under the ACA: Updated Findings from a Literature Review,” Kaiser Family Foundation, August 2019, https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-underthe-aca-updated-findings-from-a-literature-review-august-2019/. viii Examples of successful evidence-based programs include IPS Supported Employment (which places people with mental illness in competitive jobs in the community) and the comprehensive service array in First Episode Psychosis programs (FEP) that includes supported employment. Both these interventions have been shown to improve the employment outcomes of people with mental illness at rates far higher than the national average. Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Dungan, Casey Friday, October 18, 2019 2:11 PM PUBLICE NOTICE TENNCARE Cambron, Amber; Gabe Roberts [EXTERNAL] Comment Letter on TennCare Amendment 42 Amendment 42 Comment Letter_BlueCare . 10 18 2019.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please see attached comment letter regarding Amendment 42 from BlueCare Tennessee.    Casey Dungan  VP and Chief Financial Officer  1 Cameron Hill Circle  Chattanooga, TN 37402   Office: 423.535.5635         This email was sent by "Dungan, Casey" securely using Transport Layer Security (TLS).    Please see the following link for the BlueCross BlueShield of Tennessee E‐mail  disclaimer:  https://www.bcbst.com/about/our‐company/corporate‐governance/privacy‐security/email‐policy.page  1 October 18, 2019 Mr. Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Mr. Roberts: On behalf of BlueCross BlueShield of Tennessee (BCBST), I am writing to offer public comments on TennCare Waiver Amendment 42 to the TennCare II Demonstration Waiver which proposes to convert a portion of the federal share of the Medicaid funding for the core medical services program to a block grant. As you may know, BCBST has participated in the TennCare Demonstration Waiver from its inception in 1994. Over the history of the program, BCBST and TennCare leadership have worked together as the program evolved into a recognized leader in innovative approaches to administering a Medicaid program that exhibits a commitment to both quality of care and cost effective operations. Our comments focus on selected elements of the state’s request for state flexibility and its desire to fund further innovation in addressing issues that impact the health of the Medicaid members served across the state. These elements can be traced to the state’s Public Chapter (PC) 481 which charged TennCare with submitting a waiver to the Centers for Medicare and Medicaid Services (CMS) that establishes a block grant funding arrangement for the state’s Medicaid program. As outlined in the PC 481, the block grant program should provide the state with flexibility to use the experience gained from 25 years of administering the TennCare waiver program to nimbly react to cost drivers and emerging health care needs in Tennessee. In addition, the legislation also required that the requested block grant exclude costs that had not been originally included in the state’s demonstration waiver and be indexed for inflation and population growth, thus protecting the financial future of the program against sudden changes in the economy that have historically placed financial pressure on Medicaid programs across the country. The PC also instructs that the block grant waiver request should provide the state with maximum flexibility to serve additional populations with specific financial or healthcare needs. We believe the state has designed the block grant waiver request to address all the requirements of PC 481, and by doing so, created a novel approach to the traditional Medicaid block grant concept. This approach protects the state from significant financial risk from future economic uncertainty, preserves key programs by thoughtfully crafting the scope of the block grant, and promotes innovation in health care within the state by requesting flexibility to innovate through policy changes and invest shared savings from the program in key activities to pave the way for future improvements in public health. BlueCare Tennessee, an Independent Licensee of BlueCross BlueShield Association BCBST supports the state’s efforts to protect the program from financial pressures that can result from unfavorable economic cycles, changing markets and shifts in public policy. A chief criticism of using a traditional federal block grant to administer an entitlement program is that it fixes the amount of federal funding available to a program that requires more funding when state and federal economic conditions are deteriorating. Just 10 years ago, the American Recovery and Reinvestment Act (ARRA) increased the federal medical assistance percentage temporarily to help states cover the cost of increased enrollment in Medicaid combined with lower general tax revenues during a period of economic recession. The state’s plan sets the initial block grant using an average of multiple years of previous enrollment to recognize that enrollment in the program can vary significantly over time and proposes to use a commonly accepted medical trend from the Congressional Budget Office to account for the impact of inflation on the health care sector. It also provides for a set per capita increase to account for situations where enrollment grows under the existing financial eligibility criteria in response to worsening economic conditions. The state’s plan also includes a provision for new programs which are created as a result of either state or federal public policy changes. These new programs would be funded outside the block grant for a period of time until there was enough credible experience to incorporate the new program into the block grant funding cap. BCBST supports these provisions that should allow the state to maintain the program’s eligibility standards and benefits during challenging financial circumstances or changes in public policy regarding the Medicaid program. BCBST also recognizes the efforts of the state to exclude programs from the block grant that were never included in the state’s original demonstration waiver for TennCare, such as the 1915c waiver programs and targeted case management for children in state custody. The proposal also excludes cost sharing and premium assistance for members who are dual eligible for Medicaid and Medicare, as well as administrative costs not treated as medical assistance expenditures and uncompensated care funds historically authorized under the TennCare demonstration. We support the state’s decision to exclude these programs and costs from the block grant and understand that the expenditures included in the block grant represent services that BCBST currently manages for the state in its role as a managed care organization (MCO). Under the state’s block grant proposal, we believe TennCare MCOs’ role to help the state manage expenditures below inflation targets would take on additional significance, as performing below the targets will allow the program to maintain current benefits and potentially expand coverage or services to TennCare members. We support the state’s decisions to remove selected programs and expenditures from the block grant proposal and would accept our responsibility to assist the state in keeping the growth in the program’s medical trends within the proposed inflation targets. BCBST also supports the state’s proposal to share savings that are below the targeted federal expenditure ceiling and invest those savings in programs and services that will improve the health status of TennCare members and the state as a whole. The shared savings component of the proposal is a key differentiating factor from earlier designs of a Medicaid block grant program and introduces a powerful incentive to help align stakeholders in the healthcare system toward programs that will reduce cost and provide funding to positively impact the future state of health care in Tennessee. Tennessee continues to struggle in several key indicators of health status, ranking the in the bottom 10 states for low birthweight, adolescent immunizations, preventable hospitalizations, and cancer and cardiovascular deaths per 100,000.1 Tennessee also ranks 40th in the percentage of children aged 0-17 living in poverty1 and an estimated 934,300 Tennesseans are struggling with hunger and food insecurity, including over 280,000 children.2 While the state continues its efforts to address these challenges, additional funding to make strategic investments in the state’s health infrastructure would help accelerate current strategies and encourage additional investment in addressing gaps in care and access to care. Throughout its history, TennCare has been a leader in developing innovative approaches to providing high quality, high value care tailored to members’ needs. The state’s CHOICES program for individuals in need of long-term services and supports (LTSS) promoted home and community based services (HCBS) as a cost effective solution to help TennCare seniors remain in their homes. The state’s investment in the program encouraged providers to grow their presence and offerings in the state, and TennCare members’ utilization of HCBS expressed as a percentage of the population receiving LTSS increased significantly over time from 17.5% in 2010 to 42.7% in July 2019. The state’s investment in providing additional services to members or investing in the infrastructure needed to provide more convenient access to specialized systems of care could help spur improvement in the health of the TennCare population and reduce health disparities across the state. Again, BCBST endorses the state’s request to seek a shared savings approach with CMS through the waiver amendment, and we would welcome the opportunity to partner on innovative approaches to care that could be advanced with the additional federal investment in Tennessee. As BCBST reviewed the state’s block grant proposal, we found it to be developed with a clear sense of potential areas of risk for states within the traditional block grant models for Medicaid funding. BCBST appreciates the care with which the original PC 481 instructing the program to advance a block grant proposal was crafted. And it is evidenced in the efforts taken by TennCare officials to develop a plan that protects the existing program and promotes opportunities to fund innovation in the future. BCBST has outlined key areas of the proposal where we are supportive of the state’s efforts, and we would remain ready to partner with the state as needed if the state’s current proposal is accepted by CMS. We also respectfully offer a comment on the state’s request to remove the requirement for federal approval of the state’s capitation rates. As mentioned above, BCBST has served as a partner with the state in the TennCare program from the beginning, and we have seen the program weather difficult periods, learn from those challenges and make improvements to the program. We have also seen challenges faced by other states as their programs have grown and evolved over time. CMS’s role as a federal regulator for all state Medicaid programs gives them a unique vantage point when reviewing new programs and their potential impacts on capitation rate setting. With this in mind, 1 “America’s Health Rankings 2018 Annual Report”, America’s Health Rankings, United Health Foundation, www.americashealthrankings.org/explore/annual/measure/Overall/state/TN. 2 “Map the Meal Gap”, Feeding America, map.feedingamerica.org/county/2017/overall/tennessee. we request that the state continue to abide by the section of the federal regulations that requires that CMS review and approve capitation rates paid to Medicaid managed care contractors. As a final comment, we understand that the waiver amendment is a proposal to CMS to create a block grant program with TennCare and there will be multiple discussions between the state and CMS on all critical elements of the plan. We encourage the state to hold firm to the elements of the program that are designed to preserve the current benefits and eligibility criteria as well as those which offer an opportunity to help the state invest dollars saved by the program to continue to innovate and evolve the program. By doing so, we believe the state will be poised to both meet current challenges and prepare for the future of Medicaid and public health in Tennessee. Sincerely, Amber Cambron CEO, BlueCare Tennessee SVP, BlueCross BlueShield of Tennessee Jonathan Reeve From: Sent: To: Subject: Attachments: Jasper Hendricks Friday, October 18, 2019 10:26 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Letter Regarding TennCare Block Grant Proposal Nashville CARES Letter on TennCARE block grant.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good morning Director Roberts, Please see the attached letter from Nashville CARES regarding the proposed TennCare Block Grant. -jasper Jasper L. Hendricks, III Director of Advocacy & Public Policy Nashville CARES ________________________________________________ d: 615-259-4866 ext. 301 c: 615-788-4587 f: 615-467-1004 633 Thompson Lane Nashville, TN 37204 w: Nashville CARES Nashville CARES Email Disclaimer: This information is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message in error, please notify the sender immediately at the email address shown and please delete the related message from your files. 1 October 18, 2019 Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 Dear Mr. Roberts: Nashville CARES appreciates the opportunity to comment on the draft of Tennessee’s TennCare II Demonstration Amendment 42 (the “Tennessee Draft Application”) under Section 1115 of the Social Security Act. Nashville CARES is a nonprofit grassroots organization working to end the HIV/AIDS epidemic, focusing our services in Middle Tennessee. Last year, we served more than 50,000 Middle Tennesseans living with or at-risk for HIV/AIDS. Nashville CARES provides HIV prevention education, free and confidential HIV testing, and essential support services to people living with HIV.1 The implications of Medicaid funding changes for people living with HIV should be particularly important to Tennessee. HIV disproportionately burdens the South, with over half of all new HIV diagnoses in the United States occurring in Southern states like Tennessee.2 As of 2017, over 17,000 people in Tennessee were living with HIV.3 Another 2,700 Tennesseans likely don’t even know they have HIV.4 The federal government has recognized the importance of addressing the HIV epidemic here. The Centers for Disease Control and Prevention has reported that Memphis has the 8th highest rate of new HIV diagnoses among U.S. cities.5 As a result, Memphis has been targeted in President Trump’s new campaign to reduce new HIV infections.6 Meanwhile, the epidemic continues to affect the lives of people living with HIV throughout Tennessee, and disproportionately affects our communities of color and LGBTQ individuals.7 1 About Us, NASHVILLE CARES, https://www.nashvillecares.org/about/ (last visited Oct. 8, 2019). HIV in the United States by Region, U.S. CTRS. FOR DISEASE CONTROL & PREVENTION (Sept. 9, 2019) https://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html (finding that in 2017, “[t]he South made up 52% (19,968) of all new HIV diagnoses in the US”). 3 HIV Surveillance Reports, TENN. DEP’T OF HEALTH, https://www.tn.gov/health/health-programareas/statistics/health-data/hiv-data.html (last visited Oct. 8, 2019). 4 H. Irene Hall et al., Prevalence of Diagnosed and Undiagnosed HIV Infection – United States, 2008–2012, 64 CTRS. FOR DISEASE CONTROL & PREVENTION MORBIDITY & MORTALITY WEEKLY RPT. 657, 660 (2015). 5 Nat’l Ctr. for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Ctrs. for Disease Control & Prevention, Diagnoses of HIV Infection in the United States and Dependent Areas, 2017, 29 HIV SURVEILLANCE REPORT 1, 122 (2017). 6 See Jessica Holley, Shelby County Awarded Millions in Federal Funding to Fight New HIV Infections, WMC5 ACTION NEWS (Jul. 31, 2019), https://www.wmcactionnews5.com/2019/07/31/shelby-county-awarded-millionsfederal-funding-fight-new-hiv-infections/. 7 See Local Data: Tennessee, AIDSVU, https://aidsvu.org/local-data/united-states/south/tennessee/ (last visited Oct. 8, 2019) (noting that 74.3% of people living with HIV are male, and that rates of African-American males and 2 Medicaid is a critical source of health coverage for people living with HIV. Forty-two percent of adults living with HIV are covered by Medicaid, compared to just 13% of the general population.8 In Tennessee, over 600 of Nashville CARES’ 2,500 clients count on the TennCare program. These individuals rely on the Medicaid program for the health care and treatment that keeps them healthy, productive, and virally suppressed. Ensuring uninterrupted access to effective HIV care and treatment is also important to public health goals. When HIV is effectively managed and individuals stay in treatment and virally suppressed, there is no risk of transmission.9 For the reasons discussed in detail below, we oppose the Tennessee Draft Application as written. Particularly, we believe that Tennessee should eliminate its proposals for a block grant and closed formulary. I. Tennessee should eliminate its proposal for a block grant. A. The Tennessee Draft Application’s proposal of capped funding is unlawful In the Draft Application, Tennessee proposes to convert federal Medicaid funding to a modified block grant structure. Under this proposal, the federal government would pay Tennessee a fixed amount of money as a block grant, based on the number of people enrolled in each eligibility category, and adjusted forward for inflation.10 Any savings accrued from Tennessee spending less than the block grant would be split equally between the federal government and the state.11 This proposal is not one that the Secretary of Health and Human Services (HHS) could lawfully approve, because it would require waiving Medicaid requirements that are not legally waivable. Medicaid’s funding mechanisms are outlined in Section 1903 of the Social Security Act, codified at 42 U.S.C. § 1396b. Section 1903 states that the HHS Secretary “shall pay to each State…the [federal match] of the total amount expended…as medical assistance under the State plan....”12 Despite Tennessee’s assertion that a block grant would not require waiving any specific provision,13 changing the funding mechanism would clearly violate this section. Therefore, it would require a waiver for federal approval. Section 1903, however, is not a waivable provision. Under Section 1115(a) of the Social Security Act, codified at 42 U.S.C. § 1315(a), the Secretary may waive certain requirements of Medicaid; namely, those found in sections 2, 402, 454, 1002, 1402, 1602, and 1902. If Congress had intended Section 1903 to be waivable as well, it would have listed it in the statute. The Centers females living with an HIV diagnosis are 6.3 and 13.7 times higher than that of white males and females, respectively). 8 Medicaid and HIV, KAISER FAMILY FOUND. (Oct. 1, 2019), https://www.kff.org/hivaids/fact-sheet/medicaid-andhiv/. 9 Eisinger RW, Dieffenbach CW, Fauci AS. HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable. JAMA. Published online January 10, 2019321(5):451–452. doi:10.1001/jama.2018.21167. 10 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 7–9 (2019). 11 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 10 (2019). 12 Social Security Act § 1903(a)(1), 42 U.S.C. § 1396b(a)(1) (2012). 13 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 22 (2019). 2 for Medicare and Medicaid Services (CMS) itself has unambiguously stated that “Section 1115(a)(i) waiver authority extends only to provisions of section 1902 of the Act.”14 In 2018, CMS denied a Section 1115 waiver request that would have partially changed North Carolina’s federal matching rate by waiving Section 1905(b). In this denial, CMS acknowledged that it lacked the legal authority to change the Medicaid funding structure.15 The only legal way to construct Medicaid block grants or per capita caps is through a statutory change. Congress debated this kind of change in 2017,16 but ultimately decided not to pass it. HHS cannot accomplish through waivers something that the majority of Congress clearly did not intend to achieve. The HHS budget for fiscal year 2020 mentions legislative efforts to convert Medicaid to a block grant or per capita capped funding structure.17 This indicates that HHS is well aware of the fact that capped funding can only legally be accomplished by statutory change, not through a Section 1115 waiver.18 Secondly, HHS could not lawfully approve the Tennessee Draft Application because a capped funding structure would not promote the objectives of Medicaid. Section 1115(a) allows waivers for “any experimental, pilot, or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives” of Medicaid. The core objective of Medicaid, in the words of the Social Security Act, is “to furnish… medical assistance on behalf of families with dependent children and of aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services.”19 Multiple recent court decisions have repeatedly affirmed that “the ‘core’ objective of Medicaid [is] the provision of medical coverage to the needy.”20 In order to approve a Section 1115 demonstration, “the Secretary must address whether it creates a risk that beneficiaries will lose their Medicaid coverage.”21 The capped funding that Tennessee requests in its Draft Application creates such a risk. Block grant funding necessarily creates a risk of beneficiaries losing coverage. Under a block grant adjusted for medical inflation, Tennessee could expect to lose almost $2.4 billion over the next decade in federal Medicaid funding for children alone.22 Tennessee itself recognizes that a Letter from Seema Verma, Adm’r, U.S. Ctrs. for Medicare & Medicaid Servs., to Dave Richard, Deputy Sec’y for Medical Assistance, N.C. Dep’t of Health & Human Servs. (Oct. 19, 2018). 15 See Hannah Katch et al., Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grantproposal-threatens-care-for-medicaid-beneficiaries. 16 See, e.g., American Health Care Act of 2017, H.R. 1628, 115th Cong. § 121 (2017); Better Care Reconciliation Act of 2017, S. Amdt. 270 to H.R. 1628, 115th Cong. §§ 132–133 (2017); “Graham-Cassidy amendment,” S. Amdt. 1030 to H.R. 1628, 115th Cong. §§ 124–125 (2017). 17 See U.S. DEP’T OF HEALTH & HUMAN SERVS., PUTTING AMERICA’S HEALTH FIRST: FY 2020 PRESIDENT’S BUDGET FOR HHS, 69, 103 (2019). 18 See Letter from Frank Pallone, Jr., Chairman, U.S. House of Representatives Comm. on Energy & Commerce, to Alex M. Azar, Sec’y, U.S. Dep’t of Health & Human Servs. (Jun. 27, 2019). 19 Social Security Act § 1901, 42 U.S.C. § 1396 (2012). 20 Gresham v. Azar, 363 F. Supp 3d. 165, 181 (D.D.C. 2019); see also Stewart v. Azar, 313 F. Supp. 3d 237, 243 (D.D.C. 2018); Stewart v. Azar, 366 F. Supp. 3d 125, 138 (D.D.C. 2019); Philbrick v. Azar, No. 19-773, 2019 U.S. Dist. LEXIS 125678, at *24 (D.D.C. Jul. 29, 2019). 21 Philbrick v. Azar, No. 19-773, 2019 U.S. Dist. LEXIS 125678, at *25 (D.D.C. Jul. 29, 2019). 22 AVALERE HEALTH, MEDICAID BLOCK GRANTS AND PER CAPITA CAPS: PROJECTED IMPACT ON CHILDREN 8 (2019) (calculating an estimated loss of $2.39 billion in federal Medicaid funding for children from 2020 to 2029 under a block grant adjusted for medical inflation). 14 3 traditional block grant is financially risky.23 Tennessee suggests that it will mitigate this risk by increasing federal funding based on enrollment – essentially creating a per capita funding cap based on the projected costs per member used to calculate the block grant.24 Even with the Tennessee Draft Application’s proposed per capita cap, which promises “[n]o reductions in who is eligible for… TennCare,”25 gaps in coverage are likely. In fact, estimates show that a per capita cap would cost Tennessee even more in federal funding losses than a traditional block grant.26 Tennessee’s plan puts coverage at risk if per capita health costs increase faster than expected. The Tennessee Draft Application bases per capita cost increases on CBO projections,27 but there are a number of reasons why those projections might be drastically underestimated. Health care costs are difficult to estimate,28 and in several recent years, CBO has either significantly over-or under-estimated them even just a year in advance.29 In the past decade, health costs in the past decade have grown at historically low rates.30 It is still unclear whether these slowdowns are temporary or permanent, and we should not assume that increases will be this low in future years. Calculating Tennessee’s per capita inflation factor based on these projections could significantly underestimate the federal funding needed. Calculations based on regular market inflation would be even worse, since health care costs typically rise much faster than general economic inflation.31 Additionally, as the population ages, a larger portion of Tennessee Medicaid enrollees will be seniors and people with disabilities. Tennessee’s proposal to adjust the block grant based on enrollees in each category does not adequately address this shift, because population demographics are likely to shift within each category. As the “Baby Boomers” age, the population in Tennessee’s “elderly” category is likely to shift from people in their 60s and 70s to people in their 80s and 90s, who might incur Medicaid costs over 2.5 times higher.32 Because 23 DIVISION OF TENNCARE, TENNESSEE MEDICAID BLOCK GRANT PROPOSAL FREQUENTLY ASKED QUESTIONS 1 (2019). 24 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 9 (2019). 25 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 1 (2019). 26 See AVALERE HEALTH, MEDICAID BLOCK GRANTS AND PER CAPITA CAPS: PROJECTED IMPACT ON CHILDREN 10 (2019) (calculating an estimated loss of $2.55 billion in federal Medicaid funding for children from 2020 to 2029 under a per capita cap adjusted for medical inflation, compared to $2.39 billion for a block grant). 27 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 9 (2019). 28 See Jeanne M. Lambrew, Making Medicaid a Block Grant Program: An Analysis of the Implications of Past Proposals, 83 MILBANK QUARTERLY 41, 55–57 (2005) (finding less than 1/3 of growth in state and federal Medicaid costs explained by medical inflation, enrollment growth, and utilization changes combined). 29 See Edwin Park & Matt Broaddus, Medicaid Block Grant Would Shift Financial Risks and Costs to States, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 23, 2011), https://www.cbpp.org/research/medicaid-block-grantwould-shift-financial-risks-and-costs-to-states (showing variation between CBO estimates and actual costs in Figure 1). 30 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harmmillions-of (calculating that since 2010, CBO has lowered its projections for the 2011-2020 decade by 9.3 percent). 31 See Rabah Kamal & Cynthia Cox, How Has U.S. Spending on Healthcare Changed Over Time? PETERSONKAISER HEALTH SYSTEM TRACKER (Dec. 10, 2018), https://www.healthsystemtracker.org/chart-collection/u-sspending-healthcare-changed-time/. 32 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harm- 4 treatment has advanced such that HIV is a chronic condition and no longer a terminal diagnosis, people with HIV are living longer as well. People living with HIV are therefore encountering more health problems as they age. We have clients who have experienced TennCare delaying access to newer more advanced HIV medication. Additionally, Managed Care Organizations often do not have enough providers in network and a lack of culturally competent providers to meet the needs of the diverse populations and those disproportionately impacted by the HIV epidemic. Other unexpected per capita cost increases might occur in response to a public health epidemic or a costly but lifesaving medical breakthrough.33 In any of these situations, the federal block grant funding would be insufficient, and Tennessee would be left to bear all the unexpected costs. In response, it would not be surprising for Tennessee to drop coverage for beneficiaries who are most expensive to cover. These are likely to be individuals with disabilities or chronic diseases who need coverage most. Even if Tennessee does not directly cut eligibility, it could make it much harder for individuals to become or stay enrolled. The Tennessee Draft Application asks for “the flexibility to make changes to enrollment processes”34 without CMS approval. Among those changes could be requirements for enrollees to complete more paperwork or renew coverage more frequently, which have been shown to cause drops in enrollment even when eligibility rules remain the same.35 Tennessee already has a history of limiting enrollment.36 TennCare has closed enrollment37 and dropped people from coverage38 multiple times over its 25-year history. Most recently, TennCare his disenrolled 12% of children since 2016 by introduction of a new enrollment renewal millions-of (finding that “seniors aged 85 and older incurred average Medicaid costs in 2011 that were more than 2.5 times higher than those aged 65 to 74”) (emphasis in original). 33 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harmmillions-of; see also Edwin Park & Matt Broaddus, Medicaid Block Grant Would Shift Financial Risks and Costs to States, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 23, 2011), https://www.cbpp.org/research/medicaidblock-grant-would-shift-financial-risks-and-costs-to-states; Hannah Katch et al., Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grant-proposal-threatens-care-for-medicaid-beneficiaries. 34 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 19 (2019). 35 See MICHAEL PERRY ET AL., KAISER COMM’N ON MEDICAID & THE UNINSURED, MEDICAID AND CHILDREN OVERCOMING BARRIERS TO ENROLLMENT: FINDINGS FROM A NATIONAL SURVEY 8–14 (2000). 36 Hannah Katch et al., Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grantproposal-threatens-care-for-medicaid-beneficiaries. 37 See LEWIN GRP., OFFICE OF THE ASSISTANT SEC’Y FOR PLANNING & EVALUATION, ISSUES IN DEVELOPING PROGRAMS FOR UNINSURED CHILDREN: A RESOURCE BOOK FOR STATES app. A (1998), https://aspe.hhs.gov/report/issues-developing-programs-uninsured-children-resource-book-states/tenncare. 38 See Emily Siner, TennCare’s Big Cuts In 2005 May Have Delayed Breast Cancer Diagnoses, Study Suggests, NASHVILLE PUBLIC RADIO (Jun. 27, 2017), https://www.nashvillepublicradio.org/post/tenncare-s-big-cuts-2005may-have-delayed-breast-cancer-diagnoses-study-suggests; Brett Kelman, Tennessee Erased Insurance for at Least 128,000 Kids. Many Parents Don't Know, NASHVILLE TENNESSEAN (Apr. 4, 2019), https://www.tennessean.com/story/news/health/2019/04/02/tennessee-tenncare-coverkids-medicaid-erased-healthcare-coverage-for-children/3245116002/. 5 process.39 And currently, thousands of Tennesseans with intellectual or developmental disabilities remain on waiting lists for Medicaid waiver services.40 This proposed capped funding structure encourages Tennessee to limit coverage again if costs approach the federal funding cap – or even just to save money. The Tennessee Draft Application proposed funding structure creates an incentive for the state to spend as little as possible on Medicaid, so that it can receive “shared savings payments” along with the federal government. Tennessee’s promise of “state maintenance of effort,”41 assuring that it will contribute the same amount of state dollars as it typically has, is no guarantee. Tennessee is also requesting funding for “costs not otherwise matchable” to invest in services that would promote “health, not just healthcare.”42 Tennessee could easily demonstrate maintenance of effort by counting the amount of money it already spends on social services it believes support beneficiaries’ health, while at the same time reducing coverage.43 The capped funding structure proposed in the Tennessee Draft Application creates a substantial risk of coverage loss. Since capped funding is not “likely to assist in promoting the objectives”44 of Medicaid, HHS cannot approve this section of the waiver. If HHS were to approve this application, it would be arbitrarily and capriciously ignoring the objective of coverage, and this approval would be susceptible to vacatur by the federal courts. Finally, previous cases indicate that HHS could not justify approving the Tennessee Draft Application by arguing that the demonstration promotes alternative objectives of Medicaid. The D.C. District Court has held that beneficiary health and financial independence are not independently supportable objectives of Medicaid.45 Likewise, data collection for policymaking is not a Medicaid objective.46 Fiscal sustainability of the Medicaid program could be an objective, but must be weighed in the context of coverage.47 Therefore, while Tennessee has argued that their capped funding proposal “realign[s] incentives” to encourage economic savings for the federal government and the state,48 HHS must consider any such savings as secondary to the effects on health coverage. On balance, the risk to coverage clearly outweighs any resulting economic savings. 39 See Brett Kelman, Tennessee Erased Insurance for at Least 128,000 Kids. Many Parents Don't Know, NASHVILLE TENNESSEAN (Apr. 4, 2019), https://www.tennessean.com/story/news/health/2019/04/02/tennessee-tenncarecoverkids-medicaid-erased-health-care-coverage-for-children/3245116002/. 40 See, e.g., Tennessee, KIDS’ WAIVERS (Jan. 22, 2019), https://www.kidswaivers.org/tn/ (currently reporting 5813 people on waiting list); Tennessee Medicaid Waiver, MEDICAIDWAIVER.ORG, http://medicaidwaiver.org/state/tennessee.html (last visited Oct. 3, 2019) (currently reporting over 7000 people on waiting lists); Waiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waivers, KAISER FAMILY FOUND., https://www.kff.org/health-reform/state-indicator/waiting-lists-for-hcbs-waivers/ (last visited Oct. 3, 2019) (as of 2017 reporting 7248 people on waiting lists). 41 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 11 (2019). 42 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 13 (2019). 43 Hannah Katch et al., Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grantproposal-threatens-care-for-medicaid-beneficiaries. 44 Social Security Act § 1115(a), 42 U.S.C. § 1315(a) (2012). 45 See Stewart v. Azar, 366 F. Supp. 3d 125, 143–148 (D.D.C. 2019). 46 See Philbrick v. Azar, No. 19-773, 2019 U.S. Dist. LEXIS 125678, at *46–47 (D.D.C. Jul. 29, 2019). 47 See Stewart v. Azar, 366 F. Supp. 3d 125, 148–155 (D.D.C. 2019). 48 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 10 (2019). 6 Some analysts have claimed that there is precedent for Medicaid block grants, because CMS has approved capped funding in states like Rhode Island and Vermont.49 But neither of these states actually received block grant funding. These comparisons misinterpret federal budget neutrality requirements. Longstanding CMS policy has been to only approve Section 1115 demonstrations that are expected to be budget neutral for the federal government; that is, that they “do[] not result in Medicaid costs to the federal government that are greater than what the federal government’s Medicaid costs would likely have been absent the demonstration.”50 The federal government will only match costs up to what is estimated without the waiver, and states are responsible for any overspending.51 TennCare, like all Section 1115 demonstrations, is already subject to this requirement.52 In Vermont’s Global Commitment to Health and Rhode Island’s Global Consumer Choice Compact, both states simply proposed to demonstrate budget neutrality based on aggregate costs, rather than per capita costs.53 This did not result in a block grant of funding.54 Both states noted that “[t]he standard Medicaid funding process shall be used during the demonstration.”55 The federal government still reimbursed the states based on FMAP. Additionally, both approvals allowed the states to opt out of the waiver at any time,56 in case federal contributions would be needed beyond the budget neutrality cap. Vermont and Rhode Island’s waivers are very different from the block grant that Tennessee is proposing now. In addition to the fact that they did not request block grant funding, Vermont and Rhode Island’s waivers were not even primarily concerned with federal funding. The overall 49 See, e.g., Rachana Pradhan & Dan Diamond, Trump wants to bypass Congress on Medicaid Plan, POLITICO (Jan. 11, 2019), https://www.politico.com/story/2019/01/11/trump-bypass-congress-medicaid-plan-1078885. 50 Letter from Timothy B. Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to State Medicaid Director. (Aug. 22, 2018). 51 See Letter from Timothy B. Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to State Medicaid Director. (Aug. 22, 2018). 52 See Centers for Medicare & Medicaid Services Special Terms and Conditions, No. 11-W-00151/4 (attachment to Letter from Acting Adm’r & Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to Gabe Roberts, Dir. of TennCare, Tenn. Dep’t of Fin. & Admin. (Jul. 2, 2019)). 53 See Centers for Medicare & Medicaid Services Special Terms and Conditions, Global Commitment to Health Section 1115 Demonstration, No. 11-W-00194/1; Centers for Medicare & Medicaid Services Special Terms and Conditions, Rhode Island Global Consumer Choice Compact Section 1115 Demonstration, No. 11-W-00242/1. See also, Letter from Timothy B. Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to State Medicaid Director. (Aug. 22, 2018). 54 See VT. AGENCY OF HUMAN SERVS., SUMMARY OVERVIEW: GLOBAL COMMITMENT TO HEALTH MEDICAID 1115 DEMONSTRATION WAIVER, (Nov. 3, 2005) (available at DEP’T OF VT. HEALTH ACCESS, https://dvha.vermont.gov/global-commitment-to-health/2005-global-commitment-to-health-documents) (“This is not a block grant.”); Edward Alan Miller et al., Medicaid Block Grants: Lessons from Rhode Island’s Global Waiver, STATE HEALTH ACCESS REFORM EVALUATION 3 (Jun. 2013) (“[T]he waiver does not stand as an example of an actual block grant.”). 55 Centers for Medicare & Medicaid Services Special Terms and Conditions, Global Commitment to Health Section 1115 Demonstration, No. 11-W-00194/1; see also, Centers for Medicare & Medicaid Services Special Terms and Conditions, Rhode Island Global Consumer Choice Compact Section 1115 Demonstration, No. 11-W-00242/1 (replacing “shall” with “must”). 56 See Centers for Medicare & Medicaid Services Special Terms and Conditions, Global Commitment to Health Section 1115 Demonstration, No. 11-W-00194/1; Centers for Medicare & Medicaid Services Special Terms and Conditions, Rhode Island Global Consumer Choice Compact Section 1115 Demonstration, No. 11-W-00242/1. 7 purpose of the waivers was to convert the state Medicaid system from fee-for-service to managed care,57 a change that Tennessee made long before.58 Neither Vermont nor Rhode Island was given the authority to curtail enrollment or benefits,59 and in fact both used the waivers to expand coverage and services.60 These waivers do not justify the unlawful capped funding structure that Tennessee is proposing. The Tennessee Draft Application’s block grant proposal is both unprecedented and not approvable under Section 1115. B. Capped funding creates risks for Tennessee and patients The Tennessee Draft Application’s proposed funding cap would create health risks for patients. As noted previously, as Tennessee approaches its federal funding cap, it might cut eligibility or make enrollment processes more difficult. These coverage gaps have serious health impacts for patients. Health coverage increases access to regular care and management,61 which is critical for patients with chronic illnesses like HIV.62 For individuals living with HIV, treatment disruptions can harm both individual and public health. Individuals that receive regular treatment and are virally suppressed cannot transmit HIV.63 Ensuring access to care, therefore, decreases downstream health care costs. Tennessee’s past enrollment cuts have already been shown to have detrimental effects. When TennCare dropped 170,000 people due to budget pressures in 2005, the loss in coverage was associated with a serious delay in diagnosing breast cancers.64 We could also expect cuts in benefits, affordability protections, or provider payments.65 Tennessee says that “it is not its intent under this proposal to reduce covered benefits for members below their current levels.”66 But CBO notes that one of the expected consequences of a funding cap is for states to restrict benefits, causing beneficiaries to pay out of pocket or forgo 57 See VT. AGENCY OF HUMAN SERVS., OFFICE OF VT. HEALTH ACCESS, VERMONT GLOBAL COMMITMENT TO HEALTH 6 (2005); Edward Alan Miller et al., Medicaid Block Grants: Lessons from Rhode Island’s Global Waiver, STATE HEALTH ACCESS REFORM EVALUATION 3 (Jun. 2013). 58 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 1 (2019). 59 See Foley Hoag, LLP, Tennessee Announces First-in-Nation Block Grant Proposal, JD SUPRA (Sept. 23, 2019), https://www.jdsupra.com/legalnews/tennessee-announces-first-in-nation-57656/. 60 See Judith Solomon & Jessica Schubel, “Block Grant” Guidance Will Likely Invite Medicaid Waivers That Pose Serious Risks to Beneficiaries, Providers, and States, CENTER FOR BUDGET AND POLICY PRIORITIES (Jun. 27, 2019), https://www.cbpp.org/research/health/block-grant-guidance-will-likely-invite-medicaid-waivers-that-pose-seriousrisks-to. 61 See Benjamin D. Sommers et al., Health Insurance Coverage and Health — What the Recent Evidence Tells Us, 377 NEW ENG. J. MED. 586 (2017). 62 See, e.g., Brian W. Ward, Barriers to Health Care for Adults with Multiple Chronic Conditions: United States, 2012–2015, 275 NAT’L CTR. H. STATISTICS DATA BRIEF 1 (2017). 63 See Robert W. Eisinger et al., HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable. 321 JAMA 451, 451 (2019). 64 Wafa W. Tarazi et al., Impact of Medicaid Disenrollment in Tennessee on Breast Cancer Stage at Diagnosis and Treatment, 123 CANCER 3312, 3316–3317 (2017). 65 See Rachel Sachs & Nicole Huberfield, The Problematic Law And Policy Of Medicaid Block Grants, HEALTH AFFAIRS (July 24, 2019), https://www.healthaffairs.org/do/10.1377/hblog20190722.62519/full/; Judith Solomon & Jessica Schubel, “Block Grant” Guidance Will Likely Invite Medicaid Waivers That Pose Serious Risks to Beneficiaries, Providers, and States, CENTER FOR BUDGET AND POLICY PRIORITIES (Jun. 27, 2019), https://www.cbpp.org/research/health/block-grant-guidance-will-likely-invite-medicaid-waivers-that-pose-seriousrisks-to. 66 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 16 (2019). 8 services entirely.67 Tennessee has already demonstrated its willingness to cut (or at least threaten to cut) benefits due to budget concerns, as recently as this year. 68 Eight times since 2010, Tennessee has attempted to reduce benefits in order to address an anticipated budget shortfall in the fiscal year. 69 Each year, Tennessee submitted a TennCare amendment seeking to limit or eliminate coverage of selected services for TennCare eligible adults.70 Each amendment was subsequently withdrawn because the legislature reauthorized a private hospital fee reauthorization.71 Still, the threat of curtailing benefits is very real, and would be exacerbated by capped federal funding. Many people with chronic illnesses like HIV depend on the benefits provided by Medicaid, and it is inappropriate to “play chicken” with their healthcare. It also would be reasonable to expect that Tennessee might impose premiums, deductibles, or increased co-pays, all or which would discourage enrollment and access to care.72 Nashville CARES currently operates an insurance assistance program to help hundreds of our clients pay medical costs. If TennCare increased cost-sharing, hundreds more of our clients will be subjected to having to make the decision of paying for prescription medicine or fulfilling other health and social needs and therefore will be in need of financial assistance from Nashville CARES. Tennessee also might reduce payments to provider and managed care plans. The Tennessee Draft Application already requests enhanced flexibilities with respect to compensating hospitals73 and negotiating with managed care programs.74 If these flexibilities include payment cuts, it could make providers less willing to accept Medicaid patients and cause managed care plans to “shrink their provider networks, curtail quality assurance, or drop out of the program altogether.”75 Already, some rural Tennessee providers are unwilling to accept TennCare patients because of low reimbursement rates. As a result, people living with HIV need to commute long distances to receive health care services, compounding with the barriers of transportation in the state. HIV infected clients often travel an average of two hours by bus each way to their medical and social service appointments. Nashville CARES clients have experienced TennCare transportation contractor cancelling three separate scheduled pick-ups, therefore causing them to miss critical medical appointments Transportation barriers impede access and retention of care. Cutting 67 See Establish Caps on Federal Spending for Medicaid, U.S. CONG. BUDGET OFFICE (Dec. 13, 2018), https://www.cbo.gov/budget-options/2018/54726. 68 See Letter from Gabe Roberts, Dir., TennCare, to Judith Cash, Dir., State Demonstrations Grp., U.S. Ctrs. for Medicare & Medicaid Servs. (Apr. 15, 2019) (requesting Amendment 39); Letter from Gabe Roberts, Dir., TennCare, to Judith Cash, Dir., State Demonstrations Grp., U.S. Ctrs. for Medicare & Medicaid Servs. (May 29, 2019) (withdrawing Amendment 39). 69 See Letter from Gabe Roberts, Dir., TennCare, to Judith Cash, Dir., State Demonstrations Grp., U.S. Ctrs. for Medicare & Medicaid Servs. (Apr. 15, 2019) (requesting Amendment 39). 70 See, e.g., Letter from Darin J. Gordon, Dir., Bureau of TennCare, to Eliot Fishman, Dir., Family & Children’s Health Programs Grp., U.S. Ctrs. for Medicare & Medicaid Servs. (Jan. 27, 2014) (requesting Amendment 21). 71 See TennCare II Section 1115 Demonstration Fact Sheet (Feb. 2, 2016) (found at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/?entry=8387). 72 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harmmillions-of. 73 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 16 (2019). 74 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 19 (2019). 75 Establish Caps on Federal Spending for Medicaid, U.S. CONG. BUDGET OFFICE (Dec. 13, 2018), https://www.cbo.gov/budget-options/2018/54726. 9 TennCare state funding would exacerbate the problems we already face with patients being uninsured, having trouble finding providers, and having to travel long distances to obtain care.76 Capped federal funding also creates severe economic risks for Tennessee. Losing the federal entitlement buffer is dangerous for states. Currently, uncapped Medicaid serves as a “countercyclical source of federal funds for states during economic downturns.”77 Without the possibility of federal funding to respond to an economic downturn, public health crisis, or entry of a new blockbuster drug, 78 Tennessee would have to shoulder all unexpected costs. Puerto Rico, which receives modified block grant Medicaid funding, has struggled to respond to increased health needs and provider shortages after Hurricanes Irma and Maria.79 Additionally, a state requesting the first Section 1115 waiver for block grant funding would have to expect an expensive legal challenge. For example, Kentucky’s Section 1115 application for work requirements was submitted in August 2016, and now has only reached the D.C. Circuit Court of Appeals in October 2019. If Tennessee proposes a block grant, it would have to be prepared drawn-out litigation, causing uncertainty for Tennessee citizens about the future of their healthcare. For all of these reasons, the Tennessee Draft Application’s proposal of a capped funding structure is neither lawful nor a beneficial approach for Tennessee and its citizens. II. Tennessee should eliminate its proposal for a closed formulary. A. The Tennessee Draft Application’s proposed waiver of formulary requirements is unlawful Tennessee proposes that in exchange for accepting capped federal funding, it be given the flexibility to adopt a commercial-style closed formulary.80 However, HHS could not lawfully approve this proposal, since formulary requirements are not waivable. The Medicaid Drug Rebate Program requires all drug manufacturers to provide rebates to the state and federal government as a condition of having their drugs covered on Medicaid. The 76 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harmmillions-of. 77 Establish Caps on Federal Spending for Medicaid, U.S. CONG. BUDGET OFFICE (Dec. 13, 2018), https://www.cbo.gov/budget-options/2018/54726. 78 See Judith Solomon & Jessica Schubel, “Block Grant” Guidance Will Likely Invite Medicaid Waivers That Pose Serious Risks to Beneficiaries, Providers, and States, CENTER FOR BUDGET AND POLICY PRIORITIES (Jun. 27, 2019), https://www.cbpp.org/research/health/block-grant-guidance-will-likely-invite-medicaid-waivers-that-pose-seriousrisks-to. 79 See Judith Solomon, Puerto Rico’s Medicaid Program Needs an Ongoing Commitment of Federal Funds, CENTER FOR BUDGET AND POLICY PRIORITIES (Apr. 22, 2019), https://www.cbpp.org/research/health/puerto-ricos-medicaidprogram-needs-an-ongoing-commitment-of-federal-funds. 80 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 13–14 (2019). 10 program reduces state and federal spending, while still ensuring that Medicaid beneficiaries can access the drugs they need.81 Formulary requirements for states in the Medicaid Drug Rebate Program are outlined in Section 1927 of the Social Security Act, codified at 42 U.S.C. § 1396r-8. As with Section 1903 on funding, Section 1927 is not found in the list of waivable provisions under Section 1115 authority.82 The D.C. Circuit has confirmed that Section 1115 “does not authorize [the Secretary] to waive any requirements of section 1396r–8’s rebate provision.”83 In 2018, CMS also affirmed that Section 1927 is not waivable by rejecting Massachusetts’ Section 1115 proposal to create a closed formulary.84 CMS said that the only way for to implement a closed formulary would be to opt out of Section 1927 entirely, then “the state would have to negotiate directly with manufacturers and forgo all manufacturer rebates available under the federal Medicaid Drug Rebate Program.”85 Tennessee tries to sidestep the problem by proposing to waive Section 1927 indirectly. Section 1902(a)(54) of the Social Security Act requires that if a state provides coverage for outpatient prescription drugs, it must comply with the requirements of Section 1927.86 Tennessee is seeking to waive Section 1902(a)(54) insofar as it incorporates Section 1927.87 But Tennessee cannot use Section 1902(a)(54) as a loophole when Congress clearly did not enumerate Section 1927 as a waivable provision. Attempting to waive all of the requirements of Section 1927 clearly goes beyond the bounds of the Secretary’s authority under Section 1115. And this strategy is not likely to be successful – it is the same waiver of Section 1902(a)(54) that Massachusetts already proposed and CMS rejected.88 Furthermore, Tennessee has not demonstrated that a closed formulary would be an appropriate demonstration project. In order to qualify for a Section 1115 waiver, the proposal must be an “experimental, pilot, or demonstration project.” Tennessee’s justification for a closed formulary, like that of Massachusetts’ failed proposal, is purely economic. Federal courts have explained that an economic justification is not enough. “The Secretary’s obligation under § [1115] to ‘make some judgment that the project has a research or a demonstration value’ cannot be satisfied by ‘[a] simple benefits cut, which might save money, but has no research or experimental goal.’”89 81 See Edwin Park, Ctr. for Children & Families, Geo. Univ. Health Policy Inst., How to Strengthen the Medicaid Drug Rebate Program to Address Rising Medicaid Prescription Drug Costs, 5 THE FUTURE OF CHILDREN’S HEALTH COVERAGE 1, 1 (2019). 82 Social Security Act § 1115(a)(1), 42 U.S.C. § 1315(a) (2012). 83 PhRMA v. Thompson, 251 F.3d 219, 222 (D.C. Cir. 2001). 84 See Letter from Tim Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs. U.S. Ctrs. for Medicare & Medicaid Servs., to Daniel Tsai, Assistant Sec’y, MassHealth, Exec. Office of Health & Human Servs. (Jun. 27, 2018). 85 Letter from Tim Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs. U.S. Ctrs. for Medicare & Medicaid Servs., to Daniel Tsai, Assistant Sec’y, MassHealth, Exec. Office of Health & Human Servs. (Jun. 27, 2018). 86 Social Security Act § 1902(a)(54), 42 U.S.C. § 1396a(a)(54) (2012). 87 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 22 (2019). 88 See Letter from Tim Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to Daniel Tsai, Assistant Sec’y, MassHealth, Exec. Office of Health & Human Servs. (Jun. 27, 2018). 89 Newton-Nations v. Betlach, 660 F.3d 370, 381 (9th Cir. 2011) (citing Beno v. Shalala, 30 F.3d 1057, 1069 (9th Cir. 1994)). 11 Additionally, a closed formulary would not promote the goals of Medicaid. As previously noted, the primary objective of Medicaid is to “furnish medical assistance to…citizens.”90 A closed formulary restricts the scope of assistance that is provided to Tennessee citizens. Even if a closed formulary would help Medicaid be more fiscally sustainable (which, as explained below, may not be true), economic savings would have to be weighed in the context of coverage.91 A closed formulary restricts patient benefits and could lead to disenrollment for individuals who find that their necessary medications are not covered. On balance, HHS would not be able to approve this proposal. B. A closed formulary will negatively impact Tennessee and its residents Closing formularies is not a smart economic decision for a state Medicaid program. The Tennessee Draft Application proposes that it be able to “use the same tools as Medicare and commercial payers to lower drug costs.”92 But this comparison neglects important differences between Medicaid and other prescription drug coverage plans. Individuals enrolling in commercial plans or Medicare Part D have the freedom to choose a specific plan that provides the medications they need. But on Medicaid, individuals have only one plan option; most are on Medicaid because they by definition have no other choice for insurance coverage. Medicaid beneficiaries also have higher rates of chronic disease than people not on Medicaid.93 People with chronic illnesses like HIV need the flexibility of an open formulary to optimally manage their conditions. Even if Medicare were an adequate comparison, it does not enact the harsh formulary restrictions that Tennessee proposes here. Medicare Part D formularies must include at least two drugs per therapeutic category.94 CMS can require more drugs for a particularly category or class “if additional drugs present unique and important therapeutic advantages in terms of safety and efficacy, and their absence from the sponsor’s formulary would substantially discourage enrollment by beneficiaries with certain disease states.”95 Tennessee’s proposal does not adopt any such safeguards to protect the flexibility needed by patients with chronic illnesses. Nor does it include an appeals process for beneficiaries with a medical need for drugs that aren’t covered. The Medicaid Drug Rebate Program already saves states more money than commercial plans or Medicare Part D. In 2016, pharmaceutical manufacturers paid $31.2 billion in rebates to Medicaid, lowering drug costs by 51.3%.96 In contrast, in the same year, rebates negotiated by 90 Stewart v. Azar, 313 F. Supp. 3d 237, 243 (D.D.C. 2018). See Stewart v. Azar, 366 F. Supp. 3d 125, 155 (D.D.C. 2019); 92 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 13 (2019). 93 See Laura Joszt, Identifying the Most Prevalent and Costly Chronic Conditions in Medicaid, AM. J. MANAGED CARE (Nov. 28, 2017), https://www.ajmc.com/newsroom/identifying-the-most-prevalent-and-costly-chronicconditions-in-medicaid. 94 42 C.F.R. § 423.120(b)(2) (2019). 95 See U.S. CTRS. FOR MEDICARE & MEDICAID SERVS., MEDICARE PRESCRIPTION DRUG BENEFIT MANUAL, 30.2.1 (Jan. 15, 2016). 96 Edwin Park, Ctr. for Children & Families, Geo. Univ. Health Policy Inst., How to Strengthen the Medicaid Drug Rebate Program to Address Rising Medicaid Prescription Drug Costs, 5 THE FUTURE OF CHILDREN’S HEALTH COVERAGE 1, 2 (2019). 91 12 private insurers for Medicare Part D only lowered costs by 19.9%.97 Estimates indicate that Medicaid generally receives rebates of 61% off the retail price for brand-name drugs, whereas Medicare Part D only negotiates rebates to about 31% and private insurance plans achieve rebates of only 16%.98 Additionally, CBO reported that for top-selling, brand-name specialty drugs, “the average price per prescription was nearly twice as high in Medicare Part D as in Medicaid” after rebates.99 Further, a closed formulary will not produce the cost savings that Tennessee expects. Systematic reviews analyzing over 90 studies have shown that formulary restrictions have either a negative effect or no effect on pharmacy and medical costs.100 Saving money in the short-term by restricting access to necessary medications only serves to increase costs in the long-term by necessitating avoidable follow-up care for worsening conditions. Also, TennCare already has leverage to negotiate with pharmaceutical manufacturers through a preferred drug list.101 Additional leverage through a closed formulary is both unnecessary and unproductive. Most importantly, closed formularies negatively impact individual health. Formulary restrictions have been associated with lower medication adherence102 and poorer health outcomes in general.103 A fully closed formulary, like the Tennessee Draft Application proposes, would have even more severe effects. A closed formulary would be particularly harmful for individuals with chronic and complex conditions. For example, decreases in medication utilization due to closed 97 BDS. OF TRS., FED. HOSP. INS. & FED. SUPPLEMENTARY MED. INS. TR. FUNDS, THE 2018 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS 143 (2018). 98 CHARLES ROEHRIG, ALTARUM, THE IMPACT OF PRESCRIPTION DRUG REBATES ON HEALTH PLANS AND CONSUMERS 2 (2018). 99 ANNA ANDERSON-COOK ET AL., HEALTH, RETIREMENT, AND LONG-TERM ANALYSIS DIVISION, U.S. CONG. BUDGET OFFICE, PRICES FOR AND SPENDING ON SPECIALTY DRUGS IN MEDICARE PART D AND MEDICAID 5 (2018) (available at U.S. CONG. BUDGET OFFICE, https://www.cbo.gov/system/files/115th-congress-2017-2018/ presentation/53929presentation.pdf) (calculating that for the top 50 brand-name specialty drugs in Medicare Part D in 2015, average cost after rebates was $3,600 in Medicare Part D versus $1,920 in Medicaid). 100 Yujin Park et al., The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systematic Literature Review, 23 J. MANAGED CARE & SPECIALTY PHARM. 893, 898 (2017) (reviewing 59 unique studies and observing that the majority of “studies that included total or medical costs (in addition to pharmacy costs)… showed either negative effect on total, medical, or pharmacy costs or no effect on pharmacy costs”); Laura E. Happe et al., A Systematic Literature Review Assessing the Directional Impact of Managed Care Formulary Restrictions on Medication Adherence, Clinical Outcomes, Economic Outcomes, and Health Care Resource Utilization, 20 J. MANAGED CARE & SPECIALTY PHARM. 677, 681 (2014) (reviewing 93 studies and concluding “there was no distinct trend in the direction of association of economic outcomes with formulary restrictions”). 102 See Laura E. Happe et al., A Systematic Literature Review Assessing the Directional Impact of Managed Care Formulary Restrictions on Medication Adherence, Clinical Outcomes, Economic Outcomes, and Health Care Resource Utilization, 20 J. MANAGED CARE & SPECIALTY PHARM. 677, 681 (2014); Seth A. Seabury et al., Formulary Restrictions on Atypical Antipsychotics: Impact on Costs for Patients with Schizophrenia and Bipolar Disorder in Medicaid 20 AM. J. MANAGED CARE e52, e58 (2014). 103 See Yujin Park et al., The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systematic Literature Review, 23 J. MANAGED CARE & SPECIALTY PHARM. 893, 898 (2017); Seth A. Seabury et al., Formulary Restrictions on Atypical Antipsychotics: Impact on Costs for Patients with Schizophrenia and Bipolar Disorder in Medicaid 20 AM. J. MANAGED CARE e52, e58 (2014). 13 formularies are even more severe for patients with chronic illness.104 Problems with HIV medication adherence can increase the risk of drug resistance, making a patient’s drug regimen ineffective.105 In managing HIV, physicians express a need to tailor individual therapy for patients106 by trying multiple drugs in the same therapeutic class. For these patients, less restrictive formulary designs yield better outcomes and reduce costs.107 Blocking access to necessary drugs is dangerous for patients and will not produce the economic benefits Tennessee seems to expect. For these reasons, Tennessee should eliminate its proposal for a closed formulary from its Section 1115 waiver application. Conclusion Tennessee’s proposals to cap federal Medicaid funding and restrict the TennCare formulary are both improper under Section 1115 and unwise. But Tennessee does have a readily available alternative to save money: Medicaid expansion. Tennessee is forfeiting an estimated $26.1 billion over the next decade by refusing to expand Medicaid.108 Medicaid expansion would bring in more federal funding and reduce the costs of uncompensated care. With less uncompensated care, hospitals have more stability109 and cost-sharing can be lowered for people with insurance.110 Further, evidence has already shown that Medicaid expansion leads to better health outcomes, access, and affordability.111 In states that expanded Medicaid, HIV testing increased,112 allowing for earlier detection, treatment, and prevention. In expansion states, fewer people with HIV are uninsured,113 which is also linked to a lower likelihood of death in the 104 See Brenda R. Motheral & Rochelle Henderson, The Effect of a Closed Formulary on Prescription Drug Use and Costs, 36 INQUIRY 481, 485 (1999-2000). 105 See Drug Resistance, AIDS INFO (Jan. 28, 2019), https://aidsinfo.nih.gov/understanding-hiv-aids/factsheets/21/56/drug-resistance. 106 See Formulary Decision-Making Challenges in HIV, AM. J. MANAGED CARE (March 19, 2018), https://www.ajmc.com/peer-exchange/special-considerations-in-hiv-management/formulary-decisionmakingchallenges-in-hiv. 107 See James Baumgardner et al., Modeling the Impacts of Restrictive Formularies on Patients With HIV, 24 AM. J. MANAGED CARE (SPECIAL ISSUE NO. 8) SP322, SP325 (2018). 108 Louise Norris, Tennessee and the ACA’s Medicaid Expansion, HEALTHINSURANCE.ORG (Sept. 18, 2019), https://www.healthinsurance.org/tennessee-medicaid/. 109 See Richard C. Lindrooth et al., Understanding The Relationship Between Medicaid Expansions And Hospital Closures, 37 HEALTH AFFAIRS 111 (2018) (finding that states that did not expand Medicaid had a higher rate of hospital closures). 110 See Hayes McAlister, Moving the Needle for Medicaid Expansion in Tennessee Pt. 1, TENN, JUSTICE CTR. (Jul. 7, 2019), https://www.tnjustice.org/medicaid-expansion-tennessee-important-moving-the-needle/. 111 See Robin Rudowitz & Larisa Antonisse, Implications of the ACA Medicaid Expansion: A Look at the Data and Evidence, KAISER FAMILY FOUND. (May 23, 2018), https://www.kff.org/medicaid/issue-brief/implications-of-theaca-medicaid-expansion-a-look-at-the-data-and-evidence/. 112 See Yunwei Gai & John Marthinsen, Medicaid Expansion, HIV Testing, and HIV-Related Risk Behaviors in the United States, 2010–2017, 109 AM. J. PUBLIC HEALTH 1404, 1407 (2019) (finding a 3.22% increase in HIV test rates for Medicaid expansion states compared to non-expansion states). 113 See Medicaid’s Role for Individuals with HIV, KAISER FAMILY FOUND. (Apr. 18, 2017) https://www.kff.org/infographic/medicaids-role-for-individuals-with-hiv/ (finding that in expansion states, the percentage of uninsured individuals with HIV in care decreased from 14% in 2012 to 7% in 2014). 14 hospital.114 Expanding Medicaid is also an easy political choice – almost two-thirds of Tennesseans support Medicaid expansion.115 Nashville CARES thanks you for the opportunity to comment on the Tennessee Draft Application. For all of the reasons discussed above, we strongly urge Tennessee to eliminate its proposals for capped funding and a closed formulary. We also welcome the opportunity to meet with you to discuss our concerns. Yours Truly, Amna Osman, MPA CEO _____________________________________________________ d: 615-921-0215 c: 615-762-6953 HEARTLine: 1-800-467-4266 f: 615-259-4849 633 Thompson Lane Nashville, TN 37204 114 Fred J. Hellinger, In Four ACA Expansion States, the Percentage of Uninsured Hospitalizations for People With HIV Declined, 2012–14, 34 HEALTH AFFAIRS 2061 (2015) (finding that in four expansion states, hospitalizations of uninsured patients with HIV fell from 13.7% to 5.5%, while in two nonexpansion states, hospitalizations of uninsured patients with HIV increased from 14.5% to 15.7%; and finding that patients with HIV who were uninsured were 40% more likely to die in the hospital). 115 Andy Humbles, Poll: 63 Percent Support Medicaid Expansion in Tennessee, NASHVILLE TENNESSEAN (May 7, 2018), https://www.tennessean.com/story/news/2018/05/07/medicaid-expansion-poll-tennessee-support/586006002/ (reporting 63% of registered voters supporting Medicaid expansion, and only 21% opposing). 15 Jonathan Reeve From: Sent: To: Subject: Attachments: Kathy Orellana Friday, October 18, 2019 3:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] APA and Tennessee Psychiatric Association Response to TennCare Amendment 42 APA Response to TN Block Grant Comments_FINAL.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern,     Please find attached the American Psychiatric Association and Tennessee Psychiatric Association’s comments in  response to the proposed TennCare II Demonstration.     Best,     Kathy Orellana  Associate Director   Practice Management and Delivery Systems Policy  American Psychiatric Association  P: 202.559.3911   E: korellana@psych.org   www.psychiatry.org          1 October 18, 2019 Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 RE: Notice of Change in TennCare II Demonstration: Amendment 42 Dear Mr. Roberts, On behalf of the Tennessee Psychiatric Association, the medical specialty society representing 320 psychiatric physicians in the state, and the American Psychiatric Association (APA), the national medical specialty society representing more than 38,500 psychiatric physicians nationwide, we write with concern about the proposed amendment to the TennCare II Demonstration (Amendment 42). We are especially concerned that the Director’s intention to convert the bulk of TennCare’s federal funding to a block grant will limit access to quality care for Medicaid patients, particularly those with mental health and substance use disorders (MH/SUDs). The APA has historically opposed Medicaid block grants, and we strongly urge you to withdraw the proposal. Parity Compliance and Program Integrity Concerns for Medicaid Managed Care Programs Among our major concerns is Amendment 42’s proposal to provide the state with “relief from the federal requirements at 42 CFR Part 438 (concerning Medicaid managed care programs) in order to have the flexibility necessary to structure its managed care service delivery system in a manner that meets the needs of state residents and optimizes effectiveness and efficiency of operation.” The proposal delineates a non-exhaustive list of what are characterized as unnecessary federal requirements that Tennessee wants waived, including “arbitrary restrictions on the ability of managed care contractors operating fully at-risk to provide a full continuum of care for members with mental health or substance use disorder treatment needs.” We strongly oppose allowing TennCare to waive compliance with 42 CFR Part 438, which has operationalized the statutory requirements for the Medicaid program in a number of ways that are especially significant for patients with MH/SUD conditions. 42 CFR Part 438 Subpart K explicitly applies the Mental Health Parity and Addiction Equity Act (MHPAEA) compliance regulations to Medicaid managed care organizations (MCOs) and its nondiscrimination protections for patients with mental health and/or substance use disorder conditions.1 The regulations explicitly require that key program features, such as capitation rates and the scope of covered benefits, be MHPAEA compliant. These can indirectly be discriminatory and affect the scope and duration of services available for this population. Additionally, it is worrisome that the state is also asking for the flexibility to make changes to its benefits package. Without the requirements of parity compliance, we are concerned that services for the most chronically ill and complex patients would be scaled back. It is unclear from the text whether Subpart K is deemed an unnecessary federal requirement and within the scope of the contemplated provisions under 42 CFR Part 438 that Tennessee seeks relief. These patient protections are essential since the very nature of treatment for this patient population is complicated by chronic needs and the stigma surrounding their illness. For example, addiction is a complex brain disease and seeking treatment can take several attempts. According to the National Survey on Drug Use and Health, only 12 percent of the nearly 20 million adults in America who needed SUD treatment received treatment in 2018.2 These very complications have served as the basis of the historically discriminatory policies and practices of MCOs, which have unduly limited treatment for these populations and the very reason MHPAEA was enacted. To undermine its requirements would be an incomprehensible undermining of federally guaranteed patient access protections. An additional area of fundamental concern is the 438 requirements concerning network adequacy and how they fit within the context of the proposal. Network adequacy is foundational for the Medicaid program and is reflective of a key federal law requirement, the so-called “equal access provision.” This provision requires states to reimburse health care providers at a rate that is low enough to ensure efficiency and economy, yet high enough to attract a sufficient number of providers to ensure enrollees have access to health care services to the same extent they are available to the general public in the same geographic area.3 A state's Medicaid plan must provide such assurances in writing. The Medicaid statute also requires that MCOs comply with “[s]tandards for access to care so that covered services are available within reasonable time frames and in a manner that ensures continuity of care and adequate primary care and specialized services capacity”.4 How these required protections would be assured remains opaque under the proposal, and a key basis for our recommendation that it be withdrawn. The fact that the proposal’s non-exhaustive listing in this section is not definitive is a major source of concern for us, given the scope and content of 42 CFR 438. Regardless of the lack of waiver clarity, we oppose any approach whereby the state would be granted sole authority to determine if it is in 1 Code of Federal Regulations: Part 438 – Managed Care. Centers for Medicaid and Medicare Studies, October 1, 2017. https://www.govinfo.gov/content/pkg/CFR-2017-title42-vol4/xml/CFR-2017-title42-vol4-part438.xml 2 Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/ http://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR2-2016.htm 3 (42 U.S.C § 1396a(a)(30)(A)) - The Public Health and Welfare Chapter 7 - Social Security Subchapter Xix - Grants To States For Medical Assistance Programs. 4 Social Security Act § 1932(c)(1)(A)(i); see also id. § 1932(b)(5 compliance with federal law. There is a defined statutory basis for the current regulations. 42 CFR Part 438 is grounded in the directive of Section 1902(a)(4) and other sections of the Social Security Act. It requires that states provide for methods of administration that the Secretary finds necessary for proper and efficient operation of the State plan and for which the Secretary is ultimately responsible, given that federal expenditures are at issue. The Amendment text does not delineate how the state would ensure compliance with the range of essential Part 438 requirements. To cede the federal responsibility and required oversight codified in federal law is unwarranted in our view. Lastly, we are concerned that the state’s request to eliminate federal oversight on healthcare delivery may have the unintended consequence of weakening patient safeguards and health standards. Under the current TennCare Managed Care program, contractors and providers are expected to meet certain standards to protect patient access. However, Amendment 42 outlines that the state could choose to alter its delivery system in the future without needing to submit an amendment to CMS for approval. For example, in an effort to save money, the state could decide that TennCare will limit the number of days an individual can receive inpatient care, which may not be in a patient’s best interest or in line with clinical guidelines. Additionally, in attempting to control costs, MCOs often create new issues of access by imposing burdensome prior authorization requirements, implementing utilization limitations, and creating limited provider networks. Not only could these policy decisions impact patient outcomes and result in poor care, but they often raise costs by placing the burden of care elsewhere. Currently, due to the limited number of inpatient psychiatric beds, more psychiatric care is taking place in emergency departments that are often ill-equipped to handle mentally ill patients.5 Eliminating these protections would represent a significant and unwarranted undermining of federal law, which was designed to eliminate discriminatory benefit access practices, and could have a catastrophic impact on an already vulnerable patient population. If this is not the intent, it needs unequivocal clarification and an exact delineation of the protocols and policies utilized that will ensure consistency with MHPAEA compliance. Drug Formulary Impacts on Patients with Mental Illness and Substance Use Disorders Amendment 42 seeks to give the state authority to implement drug formulary management tools in an effort to manage prescription drug spending without federal oversight. “The state proposes that it have the flexibility under this demonstration to adopt a commercial-style closed formulary with at least one drug available per therapeutic class.” This proposal would mean that the drug formulary would not need to comply with Section 1927(d)(4) of the Social Security Act and would be particularly harmful for our patients. The drug formulary could no longer be required to have clinical input or all necessary medications. It is essential to acknowledge that individual drugs within the therapeutic classes used to treat psychiatrically ill patients have very different clinical indications, mechanisms of action, and side effect profiles. Drug prescribing is therefore complicated, given the nature of drug in the classes for the treatment of psychiatric disorders. These drugs are not clinically interchangeable. No two psychotropic medications have the same therapeutic effect or identical duration and intensity characteristics. 5 Nordstrom, Kimberly et al. “Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document.” Western Journal of Emergency Medicine, September 2019. https://escholarship.org/uc/item/71z0q1n8 Many mental illnesses are chronic, lifelong conditions with both acute and stable phases characterized by a broad array of symptoms, even among patients who have the same or similar diagnoses. If these mental illnesses go untreated, or are inappropriately treated, a patient’s risk of hospitalization, persistent or significant disability, or death is heightened. Although this is particularly true when a patient needs treatment for acute symptoms like suicidality or psychosis, it is also of concern during his/her ongoing “maintenance” treatment. Clinical evidence from population-based studies clearly indicates that the risk of suicide attempts and completed suicide increases for patients with any psychiatric disorder, and this risk can increase exponentially for patients who suffer from disorders like depression and anxiety, who are unable to access the antidepressants that can control their symptoms. It has been widely recognized that doctors need to have complete discretion to prescribe the most appropriate medicines for patients with these and other conditions addressed by the protected classes. Removing these critical protections may have dire health consequences for beneficiaries. A 2011 study by the American Psychiatric Institute for Research and Education studied how limited access to preferred medications impacted Medicaid patients receiving Medicare prescription drug benefits (dual eligibles). 6 These patients, who were previously stable on their medications, had to switch medications because clinically-indicated refills were not covered or approved. They also experienced significantly higher adverse events (62% versus 37%), including emergency department visits, hospitalizations, homelessness, and incarceration. The potential savings Medicaid could realize by limiting its drug formulary would be offset by the increased costs in other areas of the program and for society in general that are created by the clinical harms that will result from delaying, limiting, or denying vulnerable patients’ access to these medications. The Direct Impact of the Block Grant on Tennessee Residents Amendment 42 highlights the opportunities for cost savings to the state and the federal government as its signature goal, but it is not clear how the savings would be achieved. As written, the proposal mandates no reductions in who is eligible for TennCare, meaning that the state would likely rely on scaling back the amount of care and services enrollees are eligible to receive through the mechanisms we previously outlined to achieve Governor Lee’s projected savings of $2 billion in a year. TennCare currently covers 1.4 million of Tennessee’s most vulnerable citizens, including half of the state’s children.7 These proposed changes in Medicaid financing are especially troubling, as we consider their potential impact on individuals with mental health and substance use disorders. Due to the nature of their illness, these patients already face several barriers to care, such as not having stable housing, shortages in inpatient hospital beds, or living in rural areas with limited providers.8 They also often have co-occurring 6 Clinically Unintended Medication Switches and Inability to Prescribe Preferred Medications Under Medicare Part D. West JC, Rae DS, Mojtabai R, Rubio MS, Kreyenbuhl JA, Alter CL, Crystal S. Journal of Psychopharmacology; 2011, June 21. 7 https://www.tn.gov/tenncare/information-statistics/tenncare-overview.html 8 “The Doctor is Out: Continuing Disparities in Access to Mental and Physical Health Care.” National Alliance on Mental Illness, November 2017. https://www.nami.org/About-NAMI/Publications-Reports/Public-PolicyReports/The-Doctor-is-Out/DoctorIsOut.pdf physical conditions, and research shows that patients with serious mental illnesses die years earlier than the general population, with the majority of them dying due to physical health conditions.9 Ensuring patients have access to the treatment their doctors recommend and protecting patient safety should be a top priority for TennCare enrollees. The block grant proposal will further harm individuals already experiencing hardship. Across the country, the combined death rate for alcohol, drug, and suicide increased from 43.9% to 46.6% deaths per 100,000 people from 2016 to 2017.10 In Tennessee, the Tennessee Suicide Prevention Network found that suicide rates have increased every year since 2014 and is now the ninth-leading cause of death. According to a SAMHSA report on Tennessee’s behavioral health access, only 43.2% of adults with mental illness in Tennessee receive any form of treatment from either the public system or private providers, while the remaining 56.8% receive no mental health treatment.11 In 2017, Tennessee’s drug overdose deaths were among the highest in the nation, with 1,776 people dying of an opioid overdose.12 Enabling limited patient access to care as a way of cutting TennCare costs would worsen the current rates of the crisis. Lastly, we highlight that Tennessee currently faces the highest number of hospital closures per capita.13 Scaling back TennCare funding would not only adversely affect patients access, but would also impact the vital economic support needed by rural hospitals, physicians, and drug stores to remain open. Potential closures and loss of services to recipients will be particularly significant to rural populations. We urge you to rescind Amendment 42 and instead work on policies that enable vulnerable patients to get the care they need. We thank you for the opportunity to respond to Tennessee’s proposal. If you have questions, please contact Kathy Orellana, Associate Director of Practice Management and Delivery Systems Policy, at korellana@psych.org. We welcome the opportunity to further continue this conversation, so please feel free to reach out if you have any questions. Sincerely, Saul Levin, MD, MPA, FRCP-E CEO and Medical Director American Psychiatric Association 9 Valerie Arnold, MD, DFAPA President Tennessee Psychiatric Association Ben Druss et al. “Psychiatry’s Role in Improving the Physical Health of Patients with Serious Mental Illness.” December 2017. https://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201700359 10 “Pain in the Nation: Healthcare Systems Brief.” Trust for America’s Health and Well Being Trust. May 17, 2018. Available at http://allh.us/nq6X. 11 “Behavioral Health Barometer – Tennessee, 2015.” Substance Abuse and Mental Health Services Administration, 2015. https://www.samhsa.gov/data/sites/default/files/2015_Tennessee_BHBarometer.pdf 12 Centers for Disease Control and Prevention. (2017). [Interactive map showing number and age-adjusted rates of overdose deaths, by state]. 2017 Drug Overdose Death Rates. Retrieved from https://www.cdc.gov/drugoverdose/data/statedeaths/drug-overdose-death-2017.html 13 Alex Kent, Anna Walton. Mckenzie Regional Hospital Closure and Tennessee’s Silent Epidemic. December 2018. https://www.tnjustice.org/mckenzie-regional-hospital-closure-rural-tennessee/ Jonathan Reeve From: Sent: To: Subject: Attachments: Hayes, James Tuesday, October 15, 2019 10:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments from PPTNM Comments on TN Block Grant Waiver_PPTNM_10-15-2019.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Director Roberts,     I am emailing you to submit comments regarding Amendment 42 from Ashley Coffield, CEO and President of Planned  Parenthood of Tennessee and North Mississippi (PPTNM). Please see the attached document for PPTNM's comments  regarding the proposed amendment to TennCare.    Best,    ‐‐  James "JB" Hayes   Executive Assistant  Pronouns: he/him/his    Planned Parenthood of Tennessee and North Mississippi  D: 901.725.3034  O: 866.711.1717  plannedparenthood.org/tennessee    Support health care, education, and advocacy in our communities with your secure, online gift here.  NOTE: Confidential/Proprietary Information – This message, along with any files or attachments that may accompany it, are intended solely and exclusively for the individual or entity to which it is addressed. It contains information belonging to Planned Parenthood of Tennessee and North Mississippi that may be confidential, proprietary, privileged, or otherwise legally exempt from disclosure. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or the taking of any action in reliance on the contents of this information is strictly prohibited and may violate applicable law. If you have received this transmission in error, please notify us by telephone at (866) 711-1717 to arrange for the return of the transmission and any accompanying files.  1 October 18, 2019 VIA ELECTRONIC SUBMISSION Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: Planned Parenthood Association of Tennessee and North Mississippi Comments on Tennessee’s TennCare Section 1115 Waiver, Amendment 42 Dear Director Roberts, Planned Parenthood Association of Tennessee and North Mississippi (Planned Parenthood) submits these comments regarding the Tennessee’s Division of TennCare’s proposal (Tennessee) to convert federal funding from the federal government for the Medicaid program into a block grant. Planned Parenthood is a safety net provider for the populations in Tennessee most in need of health services. Planned Parenthood operates four health centers across the state of Tennessee and serves as a leading women’s health care provider and advocate and a trusted, nonprofit source of primary and preventive care for women, men, and young people. Our health centers range in size and locations from small rural clinic practices to larger metropolitan clinics. Every year, our health centers provide affordable birth control, lifesaving cancer screenings, testing and treatment for STDs, and other essential care to nearly 22,000 patients. The vast majority of PPTNM patients are low-income and 60 percent lack health insurance. Medicaid is a vital part of the health care system and plays a major role in ensuring access to essential primary and preventive care services for women, men, and young people. Further, approximately 1 in 5 women of reproductive age use Medicaid. The program is the largest 1 payer of reproductive health care coverage,1 paying for 75 percent of family planning services.2 And for nearly half of women giving birth, Medicaid is the source of coverage for essential care, including prenatal and delivery care; recent data found that in 24 states 50 percent or more of births are covered by Medicaid.3 Because women make up the majority of Medicaid beneficiaries, they will be disproportionately affected by Tennessee’s proposal. 4 In particular, due to racism and other systemic barriers that have contributed to income inequality, women of color disproportionately comprise the Medicaid population; 30 percent of African-American women and 24 percent of Hispanic women are enrolled in Medicaid, compared to only 14 percent of white women.5 Medicaid, as designed by Congress, is critical to improving the health and wellbeing of women and families with low incomes across Tennessee and the rest of the nation. In particular, Medicaid coverage of family planning services and supplies helps women’s health, lives, educational success, and economic empowerment. We are deeply concerned that Tennessee’s proposal to convert federal funding into a block grant for the state’s Medicaid program will undermine the goal of improving health care access for individuals with low incomes, including many of the patients that we serve. The new Section 1115 Waiver amendment (Waiver proposal) to implement a block grant would compound the threat of those in need losing access to necessary services; to accommodate the loss of federal funds, Tennessee would have to lower eligibility, restrict benefits, cut provider payments, or contribute more of its own state funds. While the stated goals of the Tennessee Section 1115 Waiver Demonstration are to improve health outcomes and promote the financial sustainability of the Medicaid program, the result will be the exact opposite and people’s health will suffer. Tennessee’s proposal to seek coverage with fixed annual funding and to deny eligible people Medicaid coverage clearly contravenes the objectives of Medicaid and does not serve a legitimate experimental purpose. The outcome is predictable – individuals and families will lose access to affordable health insurance coverage and, as a result, to critical health care services. As explained in more detail below, we strongly urge Tennessee to rescind this Waiver proposal. 1 Ranji, Usha, Medicaid and Family Planning: Background and Implications of the ACA, Kaiser Family Foundation (Feb. 3, 2016), available at https://www.kff.org/womens-health-policy/issue-brief/medicaid-and-family-planningbackground-and-implications-of-the-aca/. 2 Adam Sonfield et al., Public funding for family planning, sterilization and abortion services, FY 1980–2006, Occasional Report, New York: Guttmacher Institute, 2008, No. 38. (Jan. 2008), available at https://www.guttmacher.org/sites/default/files/pdfs/pubs/2008/01/28/or38.pdf. 3 In Tennessee, Medicaid covers 54 percent of births, Births Financed by Medicaid, Kaiser Family Foundation, https://www.kff.org/medicaid/state-indicator/births-financed-bymedicaid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. 4 Rosenbaum, Sara, What a Block Grant Would Mean for Tennessee: An Update, The Commonwealth Fund (Sep. 25, 2019), available at https://www.commonwealthfund.org/blog/2019/what-medicaid-block-grant-would-meantennessee-update (Tennessee’s plan would cap federal spending for: currently eligible poor children and adults, including pregnant women.). 5 Hannah Katch, et al., Medicaid Works for Women, Center for Budget and Policy Priorities (May 11, 2017), available at https://www.cbpp.org/research/health/medicaid-works-for-women-but-proposed-cuts-would-haveharsh-disproportionate-impact. 2 I. Tennessee’s proposal directly contravenes the purpose of the Medicaid program and would lead to enrollment and benefits cuts for those who most need coverage. Congress designed Medicaid as an entitlement program. With very few exceptions, every person who meets the eligibility criteria outlined in the Medicaid Act receives medical assistance. As a result of the Affordable Care Act, adults who do not have children and have incomes at or below 138 percent of the federal poverty level are entitled to Medicaid coverage if their states choose to expand Medicaid.6 To date, 37 states have adopted the Medicaid expansion and 14 states have not adopted the expansion, including Tennessee.7 As a result, Tennessee already lags behind in covering people with low incomes broadly and specific vulnerable populations that other states have been covering through adopting Medicaid expansion.8 Under Tennessee’s Waiver proposal, federal oversight would be eliminated and the state would be allowed to limit eligibility and cut benefits for those who qualify for Medicaid.9 This proposal clearly contravenes the objectives of Medicaid and does not serve a legitimate experimental purpose. In order to be approved pursuant to Section 1115 of the Social Security Act, Tennessee’s proposal must: ● propose an “experiment, pilot or demonstration”; ● waive compliance only with requirements in 42 U.S.C. § 1396a; ● be likely to promote the objectives of the Medicaid Act; and ● be approved only “to the extent and for the period necessary” to carry out the experiment.10 Tennessee is proposing to unreasonably limit the federal Medicaid funding the state would receive for people with low incomes who are enrolled in the state’s Medicaid program, irrespective of the actual health care costs. This is contrary to the purpose of the Medicaid 6 See 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII). Status of State Medicaid Expansion Decisions: Interactive Map, Kaiser Family Foundation (Sep. 20, 2019), available at https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactivemap/. 8 Buettgens, Matthew, The Implications of Medicaid Expansion in the Remaining States: 2018 Update, Robert Wood Johnson Foundation (May 2018), available at https://www.urban.org/sites/default/files/publication/98467/the_implications_of_medicaid_expansion_2001838 _2.pdf (Finding the more than 200,000 low-income adults in Tennessee are uninsured because of Tennessee’s refusal to expand Medicaid.). 9 TennCare II Demonstration, Project. No. 11-W-000151/4, Amendment 42, Division of TennCare, available at https://www.tn.gov/content/dam/tn/tenncare/documents2/TennCareAmendment42.pdf (The proposal would allow TennCare to limit the “amount, duration, and scope” of core benefits that TennCare is required to provide, and to limit or eliminate optional benefits, without requesting approval from the federal government or providing an opportunity for public comment.). 10 42 U.S.C. § 1315(a). 7 3 program. Medicaid is a medical assistance program, and although states have flexibility in designing and administering their Medicaid programs, the Medicaid Act requires that states provide medical assistance as far as practicable to all individuals who meet the eligibility criteria established in federal law. For over 50 years, Medicaid has operated as a federal-state partnership, with the federal government matching a fixed percentage of states’ Medicaid costs (averaging around 64 percent). The federal match helps meet each state’s Medicaid coverage costs. Indeed, if a state like Tennessee needs to spend more during a public health crisis, like the opioid epidemic, the federal government will match those costs and ensure that the state can meet the health care needs of its residents. In fact, Tennessee already benefits from a higher than average Federal Match Assistance Percentage (FMAP) at 65.21%.11 It is important to note that while Tennessee’s proposal includes a per capita adjustment to compensate for enrollment growth in the Medicaid program, this adjustment would still limit federal Medicaid contributions in the event that costs exceeded the state’s calculations. Therefore, Tennessee would still be fully responsible for the excess amount necessary to provide coverage to beneficiaries. Notably, Tennessee is a managed care state, with 93 percent of TennCare beneficiaries covered through Medicaid managed care plans.12 Without federal oversight, Tennessee would have unfettered ability to cut costs and limit benefits for those enrolled in these plans, resulting in beneficiaries having trouble accessing necessary services. Finally, Tennessee is proposing a “shared savings mechanism” that would result in the state and the federal government splitting the savings after taking into account TennCare’s actual costs versus the projected costs of the block grant. In its proposal, Tennessee claims that these savings will be “reinvested into the state” but does not provide necessary information on how these savings will be used to further the objectives of the Medicaid program. In reality, this mechanism provides a strong incentive for Tennessee to cut costs however the state sees fit in the Medicaid program, even if that means those in need will lose coverage and services. The block grant proposed by Tennessee is not likely to promote Medicaid’s objectives as there is simply no legitimate reason that a state would put itself on the line for greater financial risk rather than pursue a straightforward federal match, which the federal government pays for a majority of the costs incurred for providing coverage for individuals with low incomes, subject to no cap. By eliminating the FMAP and adopting a block grant with per capita adjustment, Tennessee’s Waiver proposal would radically restructure the state’s Medicaid program and lead 11 Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier, Kaiser Family Foundation, available at https://www.kff.org/medicaid/state-indicator/federal-matching-rate-andmultiplier/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. 12 Total MCO Enrollment, Kaiser Family Foundation, available at https://www.kff.org/other/state-indicator/totalmedicaid-mcoenrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. 4 to enrollment cuts. This runs counter to the foundational principles of Medicaid as a program that provides health care coverage for all eligible people who need it. This proposal presents a very serious threat to Tennesseeans with low incomes. As such, we strongly urge Tennessee to rescind its Waiver request. II. Tennessee’s proposal would disproportionately impact women, particularly women of color, who already face barriers to accessing care. The changes Tennessee is seeking to make to its Medicaid program would disproportionately impact women with low incomes—in particular women of color. It is clear that changing the financing structure of Medicaid into a block grant would not only disproportionately impact people enrolled in Medicaid, it would exacerbate barriers to health care access already felt by communities with low incomes and deepen health inequities, particularly among women of color. People of color face significant disparities in access to and utilization of health care, and often fare worse than white people on measures of health status and health outcomes.13 Women of color in the United States already have less access to healthy food,14 safe housing, and basic health care due to the intersections of structural racism, inequality, sexism, classism, xenophobia, and other systemic barriers. The fixed annual funding of a block grant would leave many women, particularly women15 of color, without access to care. As a result of this Waiver proposal, these populations will face worse health outcomes and continued inequities when accessing necessary health care services. This proposal presents a severe threat to women, particularly those of color, with low incomes. As such, we strongly urge Tennessee to rescind its Waiver request. III. Tennessee’s proposal to deny beneficiaries access to FDA-approved prescription drugs fails to protect beneficiary choice and access. In the Waiver proposal, Tennessee requests an unprecedented amount of authority to limit access to FDA-approved prescription drugs, without identifying any criteria for which drugs would be covered or an appeals process for individuals with a medical need for an excluded drug. The proposed changes to prescription drug policy dramatically narrow beneficiary choice and access. 13 Samantha Artiga et al., “Key Facts on Health and Health Care by Race and Ethnicity,” Kaiser Family Foundation (Jun. 7, 2016), avialabe at https://www.kff.org/disparities-policy/report/key-facts-on-health-and-health-care-byrace-and-ethnicity/. 14 Treuhaft, Sarah & Karpyn, Allison, The Grocery Gap: Who Has Access to Healthy Food and Why It Matters, PolicyLink & The Food Trust (2010), available at http://thefoodtrust.org/uploads/media_items/grocerygap.original.pdf. 15 Women of Color More Likely to be Uninsured or Covered by Medicaid, Kaiser Family Foundation, available at https://www.kff.org/women-of-color-more-likely-to-be-uninsured-or-covered-by-medicaid-womenshealth/. 5 We strongly oppose these changes, as modifications to prescription drug policy should be developed to benefit patients, with a focus on decreased costs and a commitment to robust access and choice. Tennessee’s proposed changes fail to offer sufficient safeguards to ensure that beneficiaries, including women who benefit from a vast array of choices of birth control, will continue to have access to the prescriptions of their preference. These changes also set a harmful precedent wherein drug cost is weighed more heavily than preference, absent beneficiary input. This proposal presents a very harmful threat to beneficiaries and their access to FDA-approved drugs of their choice. As such, we strongly urge Tennessee to rescind its Waiver request. *** We appreciate the opportunity to comment on Tennessee’s proposed Section 1115 waiver. We strongly urge Tennessee to rescind this Waiver proposal, as it contains provisions that would gut access to health care and undermine Medicaid coverage. If you require additional information about the issues raised in this letter, please contact Ashley Coffield (901-725-3003, acoffield@pptnm.org). Respectfully submitted, Ashley Coffield President and CEO Planned Parenthood of Tennessee and North Mississippi 2430 Poplar Ave Memphis, TN 38112 6 Jonathan Reeve From: Sent: To: Subject: Attachments: Nicole Patton Friday, October 18, 2019 9:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Comments NDSS- TennCare Comment Letter.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Hello,    Attached, please find a letter with the National Down Syndrome Society’s Public Comments for the TennCare proposal.    Thank you,  Nicole    Nicole Patton Manager of Grassroots Advocacy National Down Syndrome Society p: 646-797-6855 w: www.ndss.org e: npatton@ndss.org   1 October 9, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: The National Down Syndrome Society (NDSS) appreciates the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4). NDSS is the largest nonprofit representing and advocating for people with Down syndrome and their families. With over 400 groups internationally, NDSS has worked tirelessly on the United States federal and state levels to break down barriers and create opportunities for individuals with Down syndrome to be included in all aspects of society and fulfill their hopes and dreams. The purpose of the Medicaid program is to provide healthcare coverage for low-income individuals and families. The National Down Syndrome Society is committed to ensuring that TennCare provides quality and affordable healthcare coverage. Unfortunately, this waiver proposal to convert the funding structure of the TennCare program to a block grant will jeopardize beneficiaries’ access to care. The National Down Syndrome Society opposes Tennessee’s proposal and offers the following comments. Block Grant Structure NDSS opposes Tennessee’s proposal to change the financing structure for its Medicaid program to a block grant. NDSS fears that the state will cut coverage for certain treatments completely or impose additional barriers to important services, making it more difficult for patients to access the care that they need. Additionally, Tennessee may choose to cut payments to providers to help keep spending under the new block grant. Cuts in these programs that are critically important to people with Down syndrome, such as employment supports through Long-Term Services and Supports (LTSS), and Section 1915(c) Home and Community-Based Services (HCBS). These are optional services that states are not mandated to provide, and would likely be the first services to be cut by capped spending. As the gap between the block grant and actual costs of care increases over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients will only increase. These cuts are unacceptable. This structure will not protect either the state or beneficiaries from financial risk. The per capita adjustments to the block grant will not be sufficient if an unexpected event, such as a public health crisis, increases per-person healthcare costs. For example, there are many ground-breaking treatments in development for patients with serious and chronic illnesses. If an expensive but highly effective treatment became available, Tennessee’s spending could rise, putting the state’s budget at risk and creating an incentive for the state to impose additional barriers for that treatment. Tennessee’s proposal would include vulnerable eligibility groups such as children and people with disabilities in the block grant. We have serious concerns about how this will impact their care. Individuals with Down syndrome face a variety of health concerns, such as congenital heart defects, hearing and vision loss, respiratory problems, obstructed digestive tracts, childhood leukemia, and other health conditions. Establishing high-risk pools, defining subpopulations and/or setting fixed amounts could be complex, arbitrary, and detrimental to people with Down syndrome, many of whom would not fit neatly into one category of complexity or subpopulation. According to the National Institutes of Health, at least one-half of all people with Down syndrome also have co-occurring conditions that contribute to their medical complexity. For example, approximately half of all children with Down syndrome are born with congenital heart disease. A person with Down syndrome may also be defined as a person with a disability, a person with cancer, and a person with Autism, and a person with Alzheimer’s disease. Proposals that provide for block grants and per capita payment caps, including those that fund high-risk pools, must account for the many combinations of complicated health care needs that people with Down syndrome will face throughout their lifespan. Additionally, under this proposal, current and future administrations would not need to get approval to make changes to benefits and services, putting these patients’ care at grave risk. Some examples of this for individuals with Down syndrome:     Creating longer waiting lists for services Cutting home and community-based services and supports that make it possible to live independently and work in the community Reducing other critical services such as personal care, mental health, prescription drugs, and rehabilitative services Shifting the financial burden for health care, community supports and long-term services to families and individuals, many of whom lack financial means to provide these important services Changing TennCare to a block grant through the 1115 waiver process is illegal. The Secretary of Health and Human Services is not permitted to waive Sections 1903 and 1905, where the financing structure of the Medicaid program is located, through these types of waivers, as multiple experts have noted.1,2 Such a change would require congressional authority, yet Congress has repeatedly declined to pass legislation on this issue, most recently during the debate over repealing and replacing the Affordable Care Act in 2017. Prescription Drug Access NDSS opposes the proposal to create a closed formulary with as few as one drug per class and exclude prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated the approval process. Limiting access to medications will be detrimental to over 400,000 individuals with Down syndrome. Prescription drugs have different indications, different mechanisms of action, and different side effects, depending on the person’s diagnosis and comorbidities. Restricting TennCare’s drug benefits to a closed formulary would limit the ability of providers to make the best medical decisions for the care of their patients, effectively taking the clinical care decisions away from the doctor and patient and giving them to the state. Allowing TennCare to exclude prescription drugs approved through the FDA’s accelerated processes will harm patients by restricting access to novel and life-saving therapies. The waiver proposal does not include an appeals process for patients to access prescription drugs that are no longer covered. TennCare patients include very low-income pregnant women, the elderly, children and the blind and disabled. These individuals rely on Medicaid to provide treatment and may need access to a medication no longer covered under the new restrictions. Without an appeals process to access denied medications, these patients could experience worse health outcomes and even death. State Flexibilities NDSS opposes a number of proposals in the waiver application considered under the broad moniker of “state flexibilities.” Tennessee is asking to be exempt from federal standards and requirements for its managed care program, including the Managed Care Rule. This important safeguard ensures Medicaid Managed Care Organizations (MCOs) have to meet certain requirements related to patient care. For example, the managed care rule sets standards related to adequate networks, so patients can actually see the appropriate providers and receive the care they need. The managed care rule requires MCOs to comply with standards of time and distance to measure this network adequacy, helping patients access both primary care providers and specialists they need. Tennessee is asking to change the “amount, duration, and scope” of benefits, which could allow the state to put caps on services or only cover critical services for certain individuals. The Medicaid population, by definition, is a vulnerable population, allowing Tennessee to change the “amount, duration, and scope” of benefits could impact negatively impact patient care and outcomes. Finally, the state would no longer need to get approval to make changes to benefits and services in the future and would like to make this demonstration permanent, removing important opportunities for the public to provide feedback on the how the program is working for key stakeholders before any policies are implemented or continued. It is especially important that beneficiaries impacted by the demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint venture between Tennessee and CMS. Both entities, as well as the people it serves, should have a voice in how the program is administered. Due to advances in medical technology, individuals with Down syndrome are living longer than ever before. Today, as many as 80 percent of adults with Down syndrome reach the age of 60, and many live even longer. This necessitates access to affordable health care and long-term services and supports throughout an increased lifespan. Efforts to reform the Medicaid program should seek to address the gaps and barriers to health care that prevent individuals with Down syndrome from experience a high quality of life as they transition from childhood to working adult to senior citizen. This includes access to wellness and prevention services, health and health disparities research, patient-centered care models, and increased professional training for health care providers. Fiscal Sustainability If Tennessee is truly concerned about the fiscal sustainability of its Medicaid program, the state could submit a state plan amendment to fully expand Medicaid to 138 percent of the federal poverty level and receive a 90 percent match from the federal government for all expenses for the adult expansion population. This policy would both benefit the state financially and extend access to care to more low-income individuals in need of coverage, a core objective of the Medicaid program. Tennessee has also failed to provide a complete budget neutrality estimate with details of the projected changes in spending with the waiver and any impact on coverage. The federal rules at 431.408 pertaining to state public comment process require at (a)(1)(i)(C) that a state includes an estimate of the expected increase or decrease in annual enrollment and expenditures if applicable. The intent of this section of the regulations is to allow the public to comment on a Section 1115 proposal with adequate information to assess its impact. Given that this waiver represents a fundamental change to Tennessee’s demonstration, the state should include these projections and their impact on budget neutrality provisions. The core objective of the Medicaid program is to furnish healthcare to low-income and needy populations. This waiver does not further that goal and NDSS opposes the proposal. Thank you for the opportunity to submit comments. Sincerely, Ashley Helsing Director of Government Relations National Down Syndrome Society AHelsing@ndss.org 202-766-2407 1 Joan Alker. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown University Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/ pending-cms-guidance-on-medicaid-block-grants-executive-overreach-strikes-again/. 2 https://theincidentaleconomist.com/wordpress/tennessee-wants-to-block-grant-medicaid-is-that-legal/ Jonathan Reeve From: Sent: To: Subject: Attachments: Benjamin Chandhok Friday, October 18, 2019 1:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Arthritis Foundation Comments AF TN Block Grant Comments.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good afternoon,    Please consider the attached comments on Tennessee’s TennCare II Demonstration Amendment 42 behalf of the  Arthritis Foundation.    Thank you for your consideration,      Ben Chandhok Arthritis Foundation Senior Director of State Legislative Affairs 1615 L St. NW, Suite 320  Washington, D.C. 20036  Mobile (preferred): 513.484.7623 Office: 617-795-3888  bchandhok@arthritis.org     24/7 Helpline (1-844-571-4357)     1 ARTHRITIS FOUNDATION www.arthritis.org October 18, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: The Arthritis Foundation appreciates the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4). The Arthritis Foundation is the Champion of Yes. Leading the fight for the arthritis community, the Foundation helps conquer everyday battles through life-changing information and resources, access to optimal care, advancements in science and community connections. We work on behalf of the over 1.6 million people in Tennessee who live with the chronic pain of arthritis every day. The purpose of the Medicaid program is to provide healthcare coverage for low-income individuals and families. The Arthritis Foundation is committed to ensuring that TennCare provides quality and affordable healthcare coverage. Unfortunately, this waiver proposal to convert the funding structure of the TennCare program to a block grant will jeopardize beneficiaries’ access to care. The Arthritis Foundation opposes Tennessee’s proposal and offers the following comments. Block Grant Structure The Arthritis Foundation opposes Tennessee’s proposal to change the financing structure for its Medicaid program to a block grant. The Arthritis Foundation fears that the state will cut coverage for certain treatments completely or impose additional barriers to important services, making it more difficult for patients to access the care that they need. Additionally, Tennessee may choose to cut payments to providers to help keep spending under the new block grant. This could result in fewer Medicaid patients seen. As the gap between the block grant and actual costs of care increases over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients will only increase. The Arthritis Foundation is greatly concerned with these cuts. This structure may not protect either the state or beneficiaries from financial risk. The per capita adjustments to the block grant will likely not be sufficient if an unexpected event, such as a public health crisis, increases per person healthcare costs. For example, there are many ground-breaking treatments in development for patients with serious and chronic illnesses. If an expensive but highly effective treatment became available, Tennessee’s spending could rise, putting the state’s budget at risk and creating an added incentive for the state to impose additional barriers for that treatment. Adopting barriers like utilization management techniques such as especially stringent prior authorization and step therapy requirements can cause significant delays in treatment resulting in unnecessary trips to the hospital or emergency room. ARTHRITIS FOUNDATION www.arthritis.org Prescription Drug Access The Arthritis Foundation opposes the proposal to create a closed formulary with as few as one drug per class and exclude prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated approval process. Limiting access to medications will be detrimental to people with arthritis. Prescription drugs have different indications, different mechanisms of action, and different side effects, depending on the person’s diagnosis and comorbidities. Restricting TennCare’s drug benefits to a closed formulary would limit the ability of providers to make the best medical decisions for the care of their patients, effectively taking the clinical care decisions away from the doctor and patient and giving them to the state. Patients with autoimmune conditions like Rheumatoid Arthritis frequently require transitions to multiple medications to find a treatment that works best for them. A closed formulary can prevent patients from being able to access the best treatment for their diagnosis. The waiver proposal does not include an appeals process for patients to access prescription drugs that are no longer covered. TennCare patients include very low-income pregnant women, the elderly, children and the blind and disabled. These individuals rely on Medicaid to provide treatment and may need access to a medication no longer covered under the new restrictions. Without an appeals process to access denied medications, these patients could experience worse health outcomes and even death. State Flexibilities The Arthritis Foundation opposes a number of proposals in the waiver application considered under “state flexibilities.” Tennessee is asking to be exempt from federal standards and requirements for its managed care program, including the Managed Care Rule. This important safeguard ensures Medicaid Managed Care Organizations (MCOs) have to meet certain requirements related to patient care. For example, the managed care rule sets standards related to adequate networks, so patients can actually see the appropriate providers and receive the care they need. The managed care rule requires MCOs to comply with standards of time and distance to measure this network adequacy, helping patients access both primary care providers and specialists they need. Patients with arthritis living outside of large population centers already often must travel great distances to find specialists like rheumatologists. An exemption could cause patients to miss or skip doctor visits due to travel barriers. Tennessee is asking to change the “amount, duration, and scope” of benefits, which could allow the state to put caps on services or only cover critical services for certain individuals. The Medicaid population, by definition is a vulnerable population, allowing Tennessee to change the “amount, duration, and scope” of benefits could impact negatively impact patient care and outcomes. Finally, the state would no longer need to get approval to make changes to benefits and services in the future and would like to make this demonstration permanent, removing important opportunities for the public to provide feedback on the how the program is working for key stakeholders before any policies are implemented or continued. It is especially important that beneficiaries impacted by the demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint ARTHRITIS FOUNDATION www.arthritis.org venture between Tennessee and CMS. Both entities, as well as the people it serves, should have a voice in how the program is administered. Sincerely, Ben Chandhok Senior Director of State Legislative Affairs Arthritis Foundation Jonathan Reeve From: Sent: To: Subject: Attachments: Brenna Raines Friday, October 18, 2019 3:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] PPTA Comments on TennCare Draft Amendment 42 PPTA Comments TennCare Draft Amendment 42.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good Afternoon,    Please find attached comments from the Plasma Protein Therapeutics Association regarding TennCare Draft  Amendment 42. Contact us at the Association with any questions!    Thank you! Brenna Brenna Raines Assistant Director, Global Health Policy Plasma Protein Therapeutics Association 147 Old Solomons Island Rd Annapolis, MD 21401 443.458.4667 (office) 410.570.7175 (cell)   1 October 18, 2019 VIA EMAIL Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 RE: PPTA Comments on TennCare Draft Amendment 42 Dear Director Roberts: The Plasma Protein Therapeutics Association (PPTA) appreciates the opportunity to comment on the Draft Amendment 42 to the TennCare Demonstration (the Draft). This proposal seeks a modified version of a block grant to deliver Medicaid services in Tennessee. Although it excludes certain expenses including outpatient prescription drugs, the Draft also requests flexibility under the demonstration to adopt a commercial-style closed formulary. PPTA is concerned that this component of the Draft is inappropriate for plasma protein therapies. The application of a closed formulary on this unique class of non-interchangeable1 therapies can negatively affect care for individuals with rare and chronic conditions by interrupting their established care regimens in the absence of a justifiable medical reason. The Association and its members ask that TennCare allow its beneficiaries access to the medically appropriate plasma protein therapy recommended for them by their treating physician. PPTA is the standard-setting and global advocacy organization that represents plasma donation centers and manufacturers of plasma protein therapies. These therapies treat a variety of rare, chronic, and debilitating diseases, some with a U.S. prevalence of fewer than 100 patients. Plasma protein therapies include immune globulins to treat individuals with primary immunodeficiency diseases and chronic inflammatory demyelinating polyneuropathy; C1 esterase inhibitor to treat hereditary angioedema; Alpha-1 proteinase inhibitors to treat Alpha-1 antitrypsin deficiency, and blood clotting factors to treat individuals with bleeding disorders, such as hemophilia.2 Our membership includes Bio Products Laboratory, Biotest, CSL Behring, Emergent BioSolutions, Grifols, Kedrion, and Takeda. Plasma protein therapies are unique, non-interchangeable biologics3 made from human plasma4, or by using recombinant technology5. Patients can experience intolerance or inefficacy6 with a particular therapy but can be medically stable on another therapy that best fits their health status. It is therefore critical that the full range of plasma protein therapies be covered by TennCare so that physicians with expertise in these rare conditions can select the most medically appropriate therapy. 1 To be interchangeable, a biologic product must be “expected to produce the same clinical result as the reference product in any given patient” and “the risk in terms of safety or diminished efficacy of alternating or switching between use of the biological product and the reference product is not greater than the risk of using the reference product without such alteration or switch.” (Sections 351(k)(4)(A) and 351(k)(4)(B) of the Public Health Services Act) 2 Plasma protein therapies also treat acute conditions such as rabies, tetanus, and when pregnant women’s blood types are incompatible with their babies’ (rhesus incompatible pregnancies). 3 Public Health Services Act, supra n. 1 4 Plasma is the clear liquid portion of blood that remains after the red cells, leukocytes, and platelets are removed. 5 Recombinant therapies are only available for clotting factors and C1 esterase inhibitors; plasma-derived therapies are the only life-saving treatment for most plasma protein deficiencies. 6 Approximately one-third of patients receiving plasma protein therapies may experience intolerance to a particular product: The Immune Deficiency Foundation (IDF), Treatment Experiences and Preferences among Patients with Primary Immunodeficiency Diseases: National Survey of Patients (2013), available at https://www.primaryimmune.org/2013-idf- national-immunoglobulin-ig-treatment-survey.; The National Hemophilia Foundation, Who is at Risk for Developing an inhibitor? (July 15, 2015), available at https://www.hemophilia.org/Bleeding-Disorders/Inhibitors-Other- Complications/Inhibitors-for-Consumers/Who-is-at-Riskfor-Developing-an-inhibitor. PPTA Comments on TennCare Draft Amendment 42 October 18, 2019 Page 2 of 2 PPTA is concerned that a commercial-style closed formulary approach would exclude physicians from the treatment decision-making process. The selection of a plasma protein therapy should be made by a physician who specializes in treating these rare conditions, with consideration of the patient’s health history as well as each product’s specific approved indications and unique characteristics. Failure to make all plasma protein therapies available could force beneficiaries to switch from the product determined by the treating physician to be best for that individual, which can be both inefficient and harmful for patient health outcomes7. Policies that limit access to one therapy per class ignore expert clinical recommendations on treatment with plasma protein therapies. For example, the evidence-based guidelines for treatment with immunoglobulins published by the American Academy of Allergy Asthma & Immunology and the American Academy of Neurology state “IVIG is not a generic drug and IVIG products are not interchangeable. A specific IVIG product needs to be matched to patient characteristics to insure patient safety”8 and “Given the variable nature of these diseases, individualized treatments depending on patient need and physician judgment are important”9, respectively. These principles are echoed by the medical & scientific advisory councils of several patient advocacy organizations as well10. PPTA and its members are committed to ensuring that beneficiaries of Medicaid have appropriate access to life-saving plasma protein therapies. The use of closed formularies is problematic and potentially harmful when applied to non-interchangeable medicines such as plasma protein therapies. Any switching of therapy should be for medical purposes and driven by a physician-directed individualized approach, rather than payer-directed policies seeking more favorable rebate agreements. We request that TennCare consider the unique nature of this sector when pursuing changes in this, and any, demonstration. Thank you for considering our comments, and please feel free to contact the Association with questions. Thank you, Brenna Raines PPTA Assistant Director, Global Health Policy 7 Dangiolella, L. S., Cortesi, P. A., Rocino, A., Coppola, A., Hassan, H. J., Giampaolo, A., . . . Mantovani, L. G. (2018). The socioeconomic burden of patients affected by hemophilia with inhibitors. European Journal of Haematology,101(4), 435-456. doi:10.1111/ejh.13108; Non-Medical Switching and Step Therapy (Issue brief). (2016). Washington, DC: Hemophilia Federation of America; The Moran Company on behalf of the Institute for Patient Access. (October 2016). Cost-Motivated Treatment Changes: Implications for Non-Medical Switching (pp. 1–5). Retrieved from the IfPA website: http://allianceforpatientaccess.org/wpcontent/uploads/2016/10/IfPA_Cost-Motivated-Treatment-Changes_October-2016 8 Goldstein, S., MD, FAAAAI, & Orange, J., MD, PhD, FAAAAI. (2011, December). Eight guiding principles for safe, effective and appropriate use of IVIG (Publication). Retrieved from American Academy of Allergy Asthma & Immunology website: http://www.aaaai.org/practice-resources/practice-tools/ivig-toolkit. 9 Evidence-based guideline: Intravenous immunoglobulin in the treatment of neuromuscular disorders: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 78(13), 1009-1015. 10 Sandhaus RA, Turino G, Brantly ML, et al. The diagnosis and management of alpha-1 antitrypsin deficiency in the adult. Chronic Obstr Pulm Dis (Miami). 2016; 3(3): 668-682.; Patwa, H. S., Chaudhry, V., Katzberg, H., Rae-Grant, A. D., & So, Y. T. (2012). Zuraw BL, Banerji A, Bernstein JA, Busse PJ, Christiansen SC, Davis-Lorton M, et al. US Hereditary Angioedema Association Medical Advisory Board 2013 recommendations for the management of hereditary angioedema due to C1 inhibitor deficiency. J Allergy Clin Immunol: In Practice 2013; 1:458-67.; Medical and Scientific Advisory Council. (2005, March 12). MASAC Recommendation Regarding Factor Concentrate Prescriptions and Formulary Development and Restrictions (Publication No. 159). Retrieved from National Hemophilia Foundation website: https://www.hemophilia.org/Researchers-Healthcare-Providers/Medical-and-Scientific- Advisory-Council-MASAC/MASAC-Recommendations/MASACRecommendation-Regarding-Factor-Concentrate-Prescriptions- and-Formulary-Development-and-Restrictions. Jonathan Reeve From: Sent: To: Subject: Attachments: Brian Haile Thursday, October 17, 2019 7:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] CORRECTION: Comments on Proposed Amendment 42 Cmts on TC Amend 42 Block Grant.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   With my deepest apologies, the earlier version of this email had an error.  I have corrected that error below and  attached a revised version of our comments.    Sincerely,  Brian    From: Brian Haile   Sent: Thursday, October 17, 2019 5:28 PM  To: public.notice.tenncare@tn.gov  Subject: Comments on Proposed Amendment 42    [CORRECTED VERSION]    Dear Commissioner Roberts,    Re: Comments on Proposed Amendment 42    We are pleased to submit the attached comments in response to TennCare’s draft proposal for block grant in the draft  Amendment 42 of the TennCare II Demonstration.  Specifically, we write to propose an “Employment First” dental  benefit for adult enrollees, which we believe to be well‐aligned with TennCare’s recent proposals in Amendments 38 and 42 of the TennCare II Demonstration.      I submit these comments on behalf of my organization and:    Tatum Hauck Allsep  Founder & Chief Executive Officer, Music Health Alliance    Brandon Brown  Executive Director, Empower Tennessee    Jenny Dittes  Chief Executive Officer, HOPE Family Health    Sally Smallwood  Co‐Founder, Coalition for a Strong Tennessee    Paula Foster  Executive Director, Tennessee Conference on Social Welfare (TCSW)   1   Rachel Hester  Executive Director, Room in the Inn    Julieanna Huddle  Executive Director, Court Appointed Special Advocates of Children (CASA) Nashville    The Honorable Sharon Hurt  Executive Director, Street Works    Andrés Martínez  Director of Policy and Communications, Conexión Américas     Janie McGinley  Chief Executive Officer, Lifespan Health    Rev. Ingrid McIntyre  Executive Director and Co‐Founder, Open Table Nashville    Michael McSurdy  President & Chief Executive Officer, Family and Children’s Service    Amna Osman  Chief Executive Officer, Nashville CARES    Avi Poster  Chair, A VOICE for the Reduction of Poverty    Barbara Quinn  Chief Executive Officer, Park Center    Lisa Sherman‐Nikolaus  Policy Director, Tennessee Immigrant & Refugee Rights Coalition    Rev. Dr. Rondy Smith  Executive Director, Rest Stop Ministries    Dr. Rhonda Switzer‐Nadasdi  Chief Executive Officer, Interfaith Dental    Irwin Venick and Avi Poster  Co‐Chairs, The Nashville Jewish Social Justice Roundtable    Rev. Chris Whitney  Founder & Director, One Generation Away   Please let us know how we can help to advance such a solution.    Sincerely,  Brian Haile      2   It’s up to you to prevent the flu.  Be a Flu Fighter: Get your flu shot today!    Brian Haile   Chief Executive Officer           Pronouns: He/Him/His  bhaile@neighborhoodhealthtn.org  (615) 944‐4404 (cell)  (615) 227‐3000 (to schedule clinic appointments)  Neighborhood Health Business Office  2711 Foster Ave. Nashville, TN 37210  www.neighborhoodhealthtn.org     Celebrating Over 40 years of Success   Expanding Access to Quality Healthcare for All  This e-mail, including attachments, may include confidential and/or proprietary information, and may be used only by the person or entity to which it is addressed. If the reader of this e-mail is not the intended recipient or his or her authorized agent, the reader is hereby notified that any dissemination, distribution or copying of this e-mail is prohibited. If you have received this e-mail in error, please notify the sender by replying to this message and delete this e-mail immediately.       3 2711 Foster Avenue Nashville, TN 37210 October 17, 2019 Gabe Roberts, JD, CPA Deputy Commissioner and Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Transmitted by email to gabe.roberts@tn.gov and public.notice.tenncare@tn.gov Dear Commissioner Roberts: Re: Comments on Proposed Amendment 42 We write to propose an “Employment First” dental benefit for adult enrollees. We believe this proposal is well-aligned with TennCare’s recent proposals in Amendments 38 and 42 of the TennCare II Demonstration. Context for Our Comments Our proposal is informed by TennCare’s proposal for new work and community engagement requirements in the Amendment 38. If implemented, Amendment 38 would apply new work requirements to certain individuals enrolled in TennCare’s parent/caretaker relative eligibility group. We separately submitted comments on February 5, 2019 on this proposal to Judith Cash, Director, State Demonstrations Group, Centers for Medicare & Medicaid Services. We revisit this issue given TennCare’s pending Amendment 42 for a block grant demonstration. That proposal contemplates specific savings that TennCare “…in the health of its enrollees, not just their healthcare.” This relates in part to the stated purpose of Amendment 38 in which TennCare also seeks “…to connect individuals to employment in a way that promotes positive health outcomes.” We demonstrate here how TennCare could and should use the shared savings from Amendment 42 to achieve the intent of Amendment 38. We appreciate the chance to offer these comments on the draft Amendment 42. The text of the proposed Amendment is quite vague, which makes it difficult to offer substantive feedback. Thus, we are not able to offer an endorsement of the proposal. Nonetheless, we worked to draft a detailed response that may help inform the policy-making process. Again, we are grateful for the opportunity to offer this input. 1 1 We commend the comments submitted separately by Terri Sabella of the Tennessee Primary Care Association (TPCA), Mary Linden Salter of the Tennessee Association of Alcohol, Drug, and other Addiction Services (TAADAS), and Kristen Dinger of the Healing Trust. We urge you to consider seriously their input and recommendations as well. We also want to comment that an incorrectly designed policy or poorly implemented program can do much harm. Such policies or programs can remove the source of care on which many of the most vulnerable rely. 2 In addition, any reduction in enrollment in TennCare would further erode the stability of the safety net, 3 which provides other critical services not funded by TennCare but which are essential for the successful integration of these individuals into the workforce. For these reasons, we have taken the time to provide detailed comments below. Our hope is to enhance state policy makers’ “line of sight” into the challenges that lowerincome parents and caretaker relatives face – and illustrate some of the supports individuals may need to surmount these issues and truly succeed. Outlook and Frame of Reference We believe three key things: 1. We believe strongly in work. Evidence suggests work (either in employment or through volunteer service) can be beneficial for both physical and mental health. As we would expect, survey data reveals the majority of such parent/caretaker relatives already work. Based on our direct experience and statewide data, most of those who do not currently have a job very much want to be employed. 4 If we can work together to address their remaining barriers to employment, we can help the few remaining out-ofwork individuals to find and keep a job – and help them improve both their health outcomes and quality of life. This is central to our work and our missions. 2. Work readiness often requires dental care. Several recent summaries of the evidence suggest that appearance and oral health are critical for employment success. 5 As noted in the Tennessee Oral Health Well Being Survey, 22% of low-income adults in Tennessee say the appearance of their mouth or teeth affect their ability to interview for a job. In addition, 45% of low-income adults in Tennessee avoid smiling because of the condition of their mouth/teeth. 6 Indeed, the condition of an individual’s “social six” front teeth is highly predictive of their employability. This concern is particularly pronounced in the service sector, which is the likely source of employment for many individuals. Notwithstanding this evidence, though, TennCare does not yet cover adult dental or dentures for adult enrollees. 7 2 See generally “Medicaid Work Requirements in Tennessee.” The Sycamore Institute, 2017. Available at https://www.sycamoreinstitutetn.org/medicaid-work-requirements-in-tennessee/. 3 TennCare’s contribution to safety net funding has already declined precipitously in the past two years. For example, TennCare enrollment declined from a statewide total of above 1.55 million in June 2016 to below 1.42 million in June 2018 – and TennCare aggregate payments to providers has fallen in a commensurate fashion. For this reason, we are especially concerned about the effect of Amendment 38 for those we serve – and the sustainability of the broader safety net on which all Tennesseans rely. The sources for these data are TennCare’s enrollment statistics available at https://www.tn.gov/tenncare/information-statistics.html. 4 See generally Melton, Courtney. “Obstacles to Work among TennCare Enrollees Potentially Affected by a Work Requirement.” The Sycamore Institute, August 24, 2018. 5 See, e.g., Otto, Mary. Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. New Press, 2018. See also Jaffe, Sarah. “The Tooth Divide: Beauty, Class and the Story of Dentistry.” The New York Times, March 23, 2017, p. 21 of the Sunday Book Review. 6 American Dental Association Health Policy Institute. “Oral Health and Well-Being in Tennessee.” 2016. 7 While some enrollees are able to access certain dental services through the “Smile 180” and Smile On 60+” dental programs, the current State funding certainly does not meet the demand. 2 While we work hard to ensure our patients get these services through all available means, the reality is that many adult TennCare enrollees do not have access to dental or vision services. Their employment status and prospects reflect these sad facts. 3. Ongoing access to dental services is a powerful incentive for many adults. Primary care and emergency department services must be accessible to all under federal law. Thus, the provision (or potential removal) of health coverage may be less salient to many lower-income individuals. In this sense, Amendment 38 if implemented may only have a marginal impact on employment or community engagement. In stark contrast, lower-income individuals do highly value access to dental services. For this reason, the conditional provision of dental benefits to adult TennCare enrollees may more substantially incentivize desired behavior. This is, of course, partly a reflection of the poor oral health of our state and the memory of agonizing dental pain common experience to many adult patients. 8 These three beliefs are informed both by published evidence and our specific experiences in patient care across Tennessee. Proposal for “Employment First” Dental Benefit Given our beliefs in work and the ways to best facilitate and encourage it, we offer what we hope is a constructive proposal. Consistent with the intent of Amendment 38 and now 42, we urge TennCare to adopt an “employment first” optional dental benefit for adult enrollees. • Structure: An “employment first” optional dental benefit would provide those dental services so critical to employment readiness. Specifically, the new limited adult benefit would include at least: o 1 comprehensive exam; o 2 prophys (“cleanings”) at six-month intervals; and o As needed during the enrollee’s first benefit year:  Completion of scaling and root planning (SRP or “deep cleaning”) and 1 annual periodontal maintenance;  Unlimited number of extractions or fillings in the enrollee’s first benefit year; and  Partials and dentures. • Cost Offsets: The projected savings from Amendment 42 would offset the costs for providing this new optional benefit. • Engagement Incentives: To the extent TennCare receives federal approval to implement the employment and community engagement requirements in Amendment 38, TennCare may consider making ongoing dental benefits conditional on the these requirements. For the reasons noted above, this approach would be much more salient to enrollees and, therefore, far more likely to achieve the desired outcomes. It would 8 This also helps explain the relatively high premiums even lower-income individuals are willing to pay for dental coverage when it is available. 3 also prove a better, far more humane alternative to disenrolling nonadherent patients from the entire TennCare benefit package. Working collaboratively with its community partners, TennCare must develop a plan and secure funding to address these barriers and related issues. We stand ready to work with TennCare on a comprehensive solution, but we believe strongly any such solution must substantively address each of these challenges before finalizing and implementing Amendments 38 and 42. Please let us know how we can help to advance such a solution. Sincerely, Tatum Hauck Allsep Founder & Chief Executive Officer, Music Health Alliance Brandon Brown Executive Director, Empower Tennessee Jenny Dittes Chief Executive Officer, HOPE Family Health Sally Smallwood Co-Founder, Coalition for a Strong Tennessee Paula Foster Executive Director, Tennessee Conference on Social Welfare (TCSW) Brian Haile Chief Executive Officer, Neighborhood Health Rachel Hester Executive Director, Room in the Inn Julieanna Huddle Executive Director, Court Appointed Special Advocates of Children (CASA) Nashville The Honorable Sharon Hurt Executive Director, Street Works Andrés Martínez Director of Policy and Communications, Conexión Américas Janie McGinley Chief Executive Officer, Lifespan Health Rev. Ingrid McIntyre Executive Director and Co-Founder, Open Table Nashville 4 Michael McSurdy President & Chief Executive Officer, Family and Children’s Service Amna Osman Chief Executive Officer, Nashville CARES Avi Poster Chair, A VOICE for the Reduction of Poverty Barbara Quinn Chief Executive Officer, Park Center Lisa Sherman-Nikolaus Policy Director, Tennessee Immigrant & Refugee Rights Coalition Rev. Dr. Rondy Smith Executive Director, Rest Stop Ministries Dr. Rhonda Switzer-Nadasdi Chief Executive Officer, Interfaith Dental Irwin Venick and Avi Poster Co-Chairs, The Nashville Jewish Social Justice Roundtable Rev. Chris Whitney Founder & Director, One Generation Away 5 Jonathan Reeve From: Sent: To: Subject: Attachments: Carol Westlake Friday, October 18, 2019 10:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on Amendment 42 to TennCare Demonstration Waiver TN Disability Coalition Amendment 42 comments.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you for the opportunity to offer comments on the proposed Amendment 42 to the TennCare Demonstration  Waiver.  Our comments are attached.         Carol Westlake   Executive Director  955 Woodland St, Nashville, TN 37206  carol_w@tndisability.org   www.tndisability.org   Follow us on Twitter      1 October 18th, 2019  Gabe Roberts  Director Division of TennCare  310 Great Circle Road  Nashville, TN 37243  Re: Comment on Proposed Amendment 42 (Tennessee Medicaid Block Grant)  Dear Director Roberts:  The Tennessee Disability Coalition offers these comments on Amendment 42, which proposes to  covert federal Medicaid funding to a block grant. Our comments are based on the recommendations  and input we received from many of our over 40 member organizations and the experiences of nearly 2  million individuals with disabilities and their families in Tennessee.   Risk to Most Vulnerable Populations  TennCare, like other state Medicaid programs, helps insure some of our most vulnerable  populations including children, seniors, people with low incomes, and people with disabilities. According  to the Kaiser Family Foundation (2019), seniors and people with disabilities make up a national average  of 1 in 4 Medicaid beneficiaries while accounting for almost two‐thirds of total Medicaid spending. In  fact, the highest‐cost five percent of these enrollees account for over half of Medicaid’s national  spending.1 Private insurance is often insufficient or unattainable for people with high‐cost, low incidence  diagnoses, and typically costs about 25% more per enrollee than Medicaid because of lower Medicaid  payment rates for providers.   The Amendment 42 block grant proposal plans to alter the funding mechanism for the “core  medical services to TennCare’s core population” (pg. iv). This core population is made up of children,  seniors, people with low incomes and people with disabilities. The Amendment does not substantively  articulate the ways this systemic funding shift can produce a reduction in costs, equal or better patient  outcomes and shared cost‐savings with the federal government.   TennCare provides the fundamental care that allows us to live and contribute to our  communities and society. These services are too critical to our well‐being for the changes proposed to  proceed with as much uncertainty as is written into Amendment 42. TennCare represents a vital safety  net for our state that must be protected.   1  Kaiser Family Foundation (2019), https://www.kff.org/medicaid/issue‐brief/10‐things‐to‐know‐about‐medicaid‐ setting‐the‐facts‐straight/  1  Prescription Drug Access  The block grant proposal requests that the TennCare Bureau have flexibility under the  demonstration to adopt a commercial‐style closed formulary where as few as one drug would be  available per therapeutic class (pg. 14). Although commercial payers have the choice to elect whether or  not certain drugs are covered based on affordability and clinical efficacy, TennCare has traditionally  been required to cover any drug whose manufacturer participates in the federal Medicaid drug rebate  program.   Use of a commercial style formulary is antithetical to a safety net program such as Medicaid.   Limiting access to needed medications would be detrimental to people with disabilities and other  covered TennCare populations with chronic health needs. Prescription drugs in the same class can still  have different indications, mechanisms of actions, and side effects depending on the individual, their  diagnosis, or comorbidities. For example, we recently heard from a family in which the mother and all  three of her children have hemophilia type A. Though this disease runs in the family, the way it  manifests is as unique as a fingerprint. The mother and her children each take a separate specialty  medication based on their associated symptoms and level of efficacy.    A closed formulary’s restriction on drug benefits would also limit providers’ abilities to choose  the best medical treatment for their patients who have complex conditions, co‐morbidities, or low  incidence conditions. The proposal does not include an appeals process for individuals who may rely on  medications that are no longer covered or not included on a limited formulary. The proposed  amendment does not explain how TennCare plans to deal with this issue. If an individual is forced to  switch to a drug covered under the new restrictions and reacts poorly, there is no detail as to how the  Bureau will proceed to improve and maintain the health of the individual.   People who are Dually Eligible for Medicaid and Medicare  According to the Centers for Medicaid and Medicare Services, there were about 12 million  individuals concurrently enrolled in Medicare and Medicaid in 2017 across the nation. Dually eligible  individuals have been identified as experiencing high rates of chronic illness, as well as many having  long‐term care needs and social risk factors. CMS states that about 60% of these individuals have  multiple chronic conditions, and 49% receive long‐term care services and support.2   Of those who are enrolled in both programs, some may be full‐benefit dually eligible individuals  who are Medicare beneficiaries and also qualify for the full package of Medicaid benefits; they may  often separately qualify for assistance with Medicare premiums and cost‐sharing via the Medicare  Savings Programs (MSPs). Other individuals may be partial‐benefit dually eligible individuals and are  enrolled only in Medicare and a Medicare Savings Program.   The current language in the proposal does not make it clear whether all dually eligible  individuals, full or partial‐benefit, will be excluded. On pg. 11 of the proposal, it states “Expenditures on  behalf of individuals who are enrolled in Medicare, including cost sharing and premium assistance  (including Medicare Part D “claw back” payments) paid on behalf of individuals who are dually enrolled  in Medicare and TennCare” are not included in the proposal. On pg. 9, the proposal presents a figure of  64,679 for the number of “elderly” people to be used to calculate the base period enrollment; it  2  CMS (2019), https://www.cms.gov/Medicare‐Medicaid‐Coordination/Medicare‐and‐Medicaid‐ Coordination/Medicare‐Medicaid‐Coordination‐Office/Downloads/MMCO_Factsheet.pdf  2  specifies that Medicare members are excluded from this number. However, according to multiple  sources including the 2018 American Community Survey (ACS)3 and the Kaiser Family Foundation (KFF),  almost all seniors who are enrolled in Medicare, and even more, are enrolled in Medicaid. In 2018, the  ACS showed 138,000 individuals over age 65 who were dually enrolled in Medicare and Medicaid in  Tennessee; KFF’s findings agreed 99% of Medicaid enrollees in Tennessee over age 65 were dually  eligible. These numbers call into question whether TennCare will be excluding all persons dually eligible  from the block grant. The proposal also fails to define the “disabled” category it uses in its formula. It  does not indicate the exclusion of Medicare members. The proposal is not clear on whether all dually  eligible individuals will be excluded from the block grant. Clarification is required.  The Amendment does not provide sufficient information on the potential impact of this  proposal on the entirety of the TennCare population if the funding formula were to change. For  example, it would impact nearly all TennCare beneficiaries over 65 years old should all dually eligible  beneficiaries be excluded from the block grant. This would also affect populations like disabled adult  children who may be receiving Medicare from their retired parents but also receive Medicaid, and  Tennesseans who both have disabilities and low incomes. An individual with a disability is twice as likely  to be in poverty as someone without a disability.4 The current proposal does not acknowledge nor  specify how the block grant would affect the numerous populations that fall under dual Medicaid and  Medicare eligibility.   Impact on Long‐Term Supports and Services  Medicaid serves as the principle source of long‐term care coverage for Americans across the  nation.5 For individuals with disabilities, the coverage of long‐term supports and services through  Medicaid can be life‐saving in addition to supporting individuals to live more independent and fulfilling  lives. The proposal states that the block grant will be “calculated based on average TennCare enrollment  during State Fiscal Years 2016, 2017, 2018” (pg. iii) and does not exclude programs (pg. iv) including  CHOICES and Employment and Community First (ECF) CHOICES which provide the majority of long‐term  supports and services for people with disabilities and seniors.   The CHOICES long‐term supports and services program serves adults with disabilities and  seniors, not all of whom have access to Medicare. This program is included in the block grant (pg. iv). As  indicated above, it is unclear how the “dual” block grant exclusion applies to individuals served by  CHOICES.  The number of aging baby boomers who need services like those in CHOICES will continue to  grow, and calculations based on years past may not be able to account for or serve the people who will  need them. Block grant funding will make it hard to expand services or serve additional people as the  number of Tennesseans needing services inevitably grows.   The ECF CHOICES program provides home and community‐based (HCBS) long‐term supports and  services. The block grant will include this program serving approximately 4,000 individuals with  intellectual and developmental disabilities (pg. iv). There are currently about 7,000 additional  3  U.S. Census Bureau ‐ American Community Survey (2018), HI‐05 https://www.census.gov/data/tables/time‐ series/demo/health‐insurance/acs‐hi.html  4  NPR (2015), https://www.npr.org/sections/health‐shots/2015/07/23/424990474/why‐disability‐and‐poverty‐still‐ go‐hand‐in‐hand‐25‐years‐after‐landmark‐law  5  Kaiser Family Foundation (2019), https://www.kff.org/medicaid/issue‐brief/10‐things‐to‐know‐about‐medicaid‐ setting‐the‐facts‐straight/  3  Tennesseans already waiting to receive services on the current “referral list” for the ECF CHOICES  program. With current funding, the ECF CHOICES program is typically only able to support new enrollees  if they are in emergent need (crisis). Again, block grant funding will make it hard to expand services or  serve additional people since there are already a significant number that are not able to be served.  Thousands of young adults are already planning to graduate from high school, and as this population  ages it becomes more and more difficult for their parents/guardians to care for their adult children.  There is no evidence the program will be equipped or plans to be equipped to address the growing  need.  Changes in Amount, Scope, or Duration    Tennessee “proposes that it have the flexibility under this demonstration to make changes to its  benefits package, including the addition or elimination of optional benefits and changes in the amount,  duration and scope of covered benefits” (p.20) without notice/approval from CMS. For the vulnerable  populations Medicaid serves, changes to “amount, duration, and scope” of benefits may be detrimental  to patient care and outcomes. This could mean limiting the number of days that are covered for  necessary inpatient hospital care, limiting the number of outpatient doctor visits covered or limiting  access to durable medical equipment. Were the TennCare bureau to make a change without any  requirement for notice, an individual who relies on the optional benefits like transportation to get to  their dialysis appointments three times a week would be forced to abandon their treatments by no  choice of their own.    Another implication of TennCare’s proposal to be able to make changes to “covered benefits”  concerns whether this pertains to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT)  program for children. The draft amendment is not clear on whether EPSDT through TennCare is  impacted by the request. Federal law states children under age 21 enrolled in Medicaid are entitled to  EPSDT benefits and states must cover an array of preventive and treatment services. Since 1967, this  benefit has been a way to ensure children from birth to age 21 will receive appropriate physical, dental,  developmental, and mental health services. According to the Tennessee Commission on Children and  Youth, TennCare has on average served nearly half of all Tennessee children.6 Potential cuts or limits to  these benefits could be devastating to the lives and outcomes of Tennessee’s children and youth. It is  critical that EPSDT requirements not be waived in the TennCare program.  Impact on Newly Developing Katie Beckett Program  Tennessee children with long‐term disabilities and complex medical needs need a dedicated  pathway to Medicaid for their health and future. Just this last legislative session, the General Assembly  acted on its intention, in support of the will of the people, to assist these children and their families  through passage of a Katie Beckett waiver program. This program will allow children who have not been  eligible for Medicaid because of their parents’ incomes or assets to qualify for the care they need. These  children need access to the services provided through Medicaid and are just on the brink of getting the  help they need through the Katie Beckett program. Tennessee is waiting on approval from the Centers  of Medicaid and Medicare Services to implement this program.                                                               6  The Annie E. Casey Foundation – Kids Count Data Center (2018),  https://datacenter.kidscount.org/data/tables/2993‐youth‐on‐tenncare‐tennessees‐medicaid‐ program?loc=44&loct=2#detailed/2/any/false/37,871,870,573,869,36,868,867,133,38/any/13268,10138  4    Amendment 42 states: “The costs associated with any new population the state opts to cover in  the future, even if it would otherwise be considered a core population, will be excluded from the block  grant calculations for a period of years until the state has enough experience paying for services for this  population to update the block grant formula in a financially sound manner” (pg. iv). This point  continues on pg. 11, “Avoiding Disincentives for Future Program Changes,” which proposes, “the state  anticipates that such expenditures would be financed outside of the block grant via the traditional  Medicaid financing model for a period of up to three years. Once the state and CMS have sufficient  experience with the program modification, the state’s block grant amount will be adjusted accordingly  so that the new expenditures can be integrated into the block grant.”   This implies that new programs, including the Katie Beckett Program, will not be funded  through the block grant for up to their first three years of operation. At that time, the funding the  program has needed for operations (whether or not enrollment is at full capacity) will be the funding  allotted for the future of the program through the block grant. The Tennessee General Assembly  allocated $27.3 million of state dollars to fund this essential program for our kids with the expectation  the money would be matched by federal dollars for a total program budget of $72 million. There must  be a mechanism to protect the General Assembly’s commitment to fund this program at this funding  level.  Beyond the block grant, other aspects of Amendment 42 are also troubling for the Katie Beckett  program. Most children who are waiting to enroll in the Katie Beckett program depend on off‐label  medications for their day‐to‐day survival. The closed formulary change proposed in the block grant  could exclude the drugs that are essential to their health. All children enrolled in TennCare should have  access to EPSDT, which may or may not be impacted by this proposal. The proposal’s request to make  changes including cuts to the “amount, scope, and duration” (pg. iv) of benefits provided through  TennCare could dramatically undercut the effectiveness of the Katie Beckett program. Reducing the  Medicaid services legislators and the community fought for these children to get would be devastating.  Many of the families of these children with disabilities have already tried private insurance and found it  insufficient to keep their children healthy and thriving and that is why they fought for this program. Like  CHOICES and ECF CHOICES, Katie Beckett would be yet another program that would be difficult to  sustain and impossible to expand under the terms of the block grant.  Lack of Details and Permission to be Excused from Oversight   Medicaid is an essential safety net that represents a shared commitment of the state and the  federal government to the health and vitality of all Americans. This 60‐year partnership is based on a  foundation of joint funding and shared oversight. These checks and balances were created to ensure the  Medicaid program provides fair and equal care. Amendment 42, as written, proposes explicit  permissions to be excused from federal oversight. It offers a lack of details as to how it will protect the  individuals it serves now and in the future or how it plans to save money in the process.  On pg. 18, the  proposal asserts, “In the cases of mature demonstrations like TennCare (which have been re‐approved  multiple times and which have demonstrated positive results), CMS should re‐evaluate its current policy  to allow for a more permanent approval status.” In this, Tennessee is asking to never have to reapply or  have TennCare re‐evaluated by the federal government. This would remove essential oversight of the  program. Federal oversight has traditionally been critical to protecting people with disabilities.   The proposal also asks for the flexibility to vary benefits packages for different members (p. 16),  in contrast to the current federal requirement of comparability (covered benefits for all covered  5  populations must be the same within a state) (p.15). In addition, it proposes the flexibility to make  changes to benefits packages, adding or eliminating optional benefits and changing the amount,  duration, and scope of covered benefits (p. 20). “Given the proposed changes to the state’s federal  funding, it is expected that Tennessee will be exempt from any new federal mandates over the life of  the demonstration that could have a material impact on the state’s Medicaid expenditures (pg. 11).”  This means, for example, if the federal government mandated that states cover a particular medication  or provide a new type of service, Tennessee would be exempt from that rule and not have to do so. For  example, recent medical advances have developed a cure for hepatitis C; a debilitating and potentially  lethal disease of the liver. The drugs to cure hepatitis C are expensive and range from $80‐$150,000 per  treatment regimen. However, less‐expensive and less‐effective drugs spread over the course of an  entire lifetime could easily dwarf the cost to cure the disease outright.  Future Outlook  For 60 years Tennesseans, like all Americans, have had the certainty of a comprehensive  Medicaid program should they need it. Should Tennesseans face disability, a catastrophic illness or  dramatic economic downturn we need the certainty of a pathway to basic care through Medicaid.   Converting Medicaid funding into a block grant introduces significant uncertainty into what should be a  cornerstone of our democracy. For our most vulnerable, including children and adults with disabilities  and growing baby boomer population whose services will be impacted by the block grant, the lack of  essential details about this proposed change is unacceptable. There is no room in this block grant  proposal to serve individuals already on “referral lists” who are waiting for services and folks who will  need these services soon. Proposed changes are coupled with significantly reduced oversight of a  complex and important program. This would leave the people served unprotected.  Public feedback is important to ensuring the quality and success of any public program. Were  the provisions of Amendment 42 to go into effect and new policy changes made without notice or public  input, there is increased risk of leaving people behind and the program failing to meet the needs of  those it was designed to serve. The proposed amendment asks to start Tennessee down a “pathway to  permanency” for the waiver. With so much uncertainty about the ability of this proposal to maintain  quality healthcare for Tennesseans and to improve rather than hurt our healthcare system, there must  be opportunity for revision.    On behalf of the Tennessee Disability Coalition, Executive Director  6  Jonathan Reeve From: Sent: To: Subject: Attachments: Carrie Hobbs Guiden Wednesday, October 16, 2019 10:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] The Arc Tennessee public comment on Amendment 42 The Arc TN public comment-amendment 42 final.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Greetings, Attached and below is The Arc Tennessee public comment on Amendment 42 – TennCare’s proposal for a medicaid block grant. Thank you. October 16, 2019 Mr. Gabe Roberts Deputy Commissioner Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Mr. Roberts, On behalf of The Arc Tennessee board, staff, and members, thank you for the opportunity to provide public comment on Amendment 42, a proposal that would convert a portion of the TennCare program to a block grant. The Arc Tennessee is a statewide advocacy organization for people with intellectual and developmental disabilities and their families. We have an affiliated network of fifteen local chapters throughout the state as well as an affiliation with our national office, The Arc of the United States. The Arc Tennessee opposes the conversion of the federal Medicaid program to a block grant, and we oppose the conversion of any portion of the TennCare program to a block grant. Governor Bill Lee has suggested that advocates “do not understand block grants,” and that we are misinformed about Amendment 42. On the contrary, advocates DO understand block grants. We DO understand Amendment 42. It is precisely because we understand both block grants and Amendment 42 that we oppose them. While Amendment 42 certainly attempts to lay out a convincing argument for conversion to a block grant by explaining all the money that Tennessee is “losing” to the federal government by operating TennCare so efficiently under its current 1115c waiver, what it fails to do is provide any substance related to how the money would be used to improve the overall health of Tennessee’s most vulnerable citizens. TennCare insures approximately 18% of the state’s most vulnerable populations. According to the Sycamore Institute, Tennessee ranks 45th out of the 50 states in overall health of its citizens, 46th in obesity, 45th in diabetes, and 45th in depression. Governor Lee, the state legislature, and TennCare cannot expect advocates to blindly accept a proposal that fails to provide any detail as to how the additional money would be used to 1 improve the health of its members or how to expand benefits to additional populations, especially since the proposal bears little evidence of taking into consideration the concerns of the various advocacy groups. Furthermore, Amendment 42 relies upon the premise that both TennCare and the federal government have the data systems and processes in place to actually implement the funding mechanisms proposed in an efficient and timely matter. Historically, TennCare does not have a strong track record related to data and payment systems. There were significant challenges with 1915c service payments when they were transitioned from DIDD to TennCare, and providers had difficulty getting reimbursed. TennCare did not have the necessary systems in place for online applications when the ACA became law and people had to use the marketplace instead. More recently, thousands of Tennessee children were reportedly disenrolled from TennCare even though they were still eligible – presumably due to errors in redetermination paperwork getting where it needed to be. This history suggests that there will be challenges implementing Amendment 42 that would negatively impact its members and providers of services. In addition to our general concerns, The Arc Tennessee and its members have many concerns about how Amendment 42 will impact Tennesseans with intellectual and developmental disabilities and their families. There are approximately 7,000 people with intellectual and developmental disabilities on the "referral list" for the Employment and Community First (ECF) CHOICES program. ECF CHOICES provides home and community-based (HCBS) long term services and supports (LTSS). There is nothing in Amendment 42 to suggest that this “referral list” will be addressed with the additional money that TennCare claims will be available through this proposal. Historically, block grant funding creates significant challenges to expanding services or to serving additional people. ECF CHOICES has demonstrated a level of success in providing cost effective services for young adults with I/DD exiting school, but without additional funding, ECF CHOICES will continue its pattern of only being able to support people with emergent need (crisis). With an aging population, people with I/DD will be at great risk when their families are no longer able to care for them and no services are in place. This pattern of service provision is NOT cost effective. Amendment 42 demonstrates no acknowledgement of this population nor the thousands of young adults with I/DD that will be graduating from our schools in the coming years. Amendment 42 requests that TennCare be exempt from future federal Medicaid mandates. This means that TennCare would be exempt from any federal mandate that, for example, requires a new service, coverage for a particular medication, or even coverage for a particular population. This means if the Centers for Medicare and Medicaid services ever made HCBS LTSS mandatory (change the institutional bias) that TennCare would be exempt from that change. For people with I/DD, this means they would lose out on a critical federal change that would positively impact their lives. Amendment 42 requests permission to shift to a commercial-style closed prescription drug formulary instead of having to cover all prescription medications included in the federal Medicaid drug rebate program. This move to a commercial-style closed prescription drug formulary means TennCare could significantly limit the prescriptions covered, in particular specialty medications that could benefit a discrete population of people. For people with I/DD in particular, especially those dually diagnosed with a co-occurring mental illness, they often do not respond to the medications in the same way as someone without an I/DD. For individuals with particularly challenging behavioral health needs, it is critical that they have access to the most cutting-edge medications available to help manage their conditions. A closed prescription drug formulary that only requires 1 drug per diagnosis will negatively impact the health and safety of this population. Amendment 42 requests TennCare be exempt from the federal Medicaid comparability mandate that requires covered benefits extend to all covered populations. Historically, people with I/DD have been a low priority with respect to covered services or expansion of HCBS LTSS. We are concerned that being exempt from the federal Medicaid comparability mandate will lead to people with I/DD struggling to access to the types of services they need even more than they struggle to now, which will adversely impact their health and safety. 2 Amendment 42 requests that TennCare be exempt from reapplying to CMS or being re-evaluated by the federal government. No program should be exempt from some level of oversight by its funder. No state agency would presume its vendors/contractors be exempt from their oversight. Removal of any level of federal oversight for the TennCare program is particularly troubling for people with I/DD and their families. Federal oversight has traditionally been critical to protecting people with I/DD because states have not done the right thing for this population. It took the federal Justice Department’s lawsuits against the state’s Arlington and Cloverbottom Developmental Centers, and ongoing federal oversight, for Tennessee to begin offering community-based services for people with I/DD. The Americans with Disabilities Act (ADA) was and is necessary because states didn’t voluntarily make buildings accessible. The Individuals with Disabilities Education Act (IDEA) was and is necessary because states did not see the need to provide a free and appropriate public education to children with I/DD. While the federal government is far from perfect, its oversight is necessary to protect the rights of people with I/DD. Amendment 42 requests that TennCare be allowed to make changes to the benefits it provides, TennCare enrollment processes, and service delivery systems without federal government approval or oversight. Again, federal oversight has traditionally been critical to protecting people with I/DD. Without that additional level of oversight, TennCare has the ability to limit TennCare eligibility for people with I/DD who are a traditionally more expensive population to support. This population is an easy target if funding becomes tight. Lastly, while the new Katie Beckett program will not be included in the block grant for the first three years of operation, after that time, the funding needed for operations (whether or not enrollment is at full capacity) will be through the block grant. We are deeply concerned that eligibility for the Katie Beckett program will be restricted in the name of cost containment, and that children with complex disabilities and medical needs will be adversely impacted as a result. It is extremely difficult for The Arc Tennessee and its members to hear Tennessee brag about how much money Tennessee has saved with TennCare over the years, yet for nearly 20 years there has been 6,0007,000 people with I/DD waiting for needed services. Though you mention in Amendment 42 about how TennCare’s efficiency has only benefited the federal government, you make no mention of how that money could have been used to address unmet needs if it had stayed in the program. It is also extremely difficult for us to hear Tennessee brag about how much money TennCare and the state have in their “rainy day” funds when we were the only state that did not have a true Katie Beckett program. It took the mobilization of hundreds of families who have children with complex disabilities and the work of disability advocacy organizations to pass a law requiring the creation of the program. It also took legislation to address the needs of aging caregivers who were caring for their adult children with I/DD. Again, disability advocacy organizations had to mobilize families to draw attention to this critical need. Only because a law was passed do people with I/DD living with caregivers aged 75 and older get access to HCBS LTSS before reaching an emergent (crisis) status. We frequently hear from families of children and adults with I/DD who experience difficulties getting needed services now even though they receive TennCare and ECF CHOICES benefits. Amendment 42 requests to do away with federal safeguards governing the MCOs, which includes ensuring that they have adequate provider networks, pay providers promptly, and use actuarially sound rates. If the provider network is a challenge now, what will the future hold when the block grant funding isn’t sufficient to meet the needs of this population and the provider pool shrinks even more? The Arc Tennessee, its members, and the disability community have been asked to blindly trust the state of Tennessee and TennCare to do what is right for people with I/DD. As we have demonstrated in this letter, history prevents it from even remotely being a possibility. We oppose Amendment 42 and any attempt to convert TennCare funding to a block grant. Thank you again for the opportunity to submit public comment on Amendment 42. Should you have any questions, you may reach me at cguiden@thearctn.org. 3 Sincerely, Carrie Hobbs Guiden Executive Director   Doria Panvini Public Policy Committee Chair Carrie Hobbs Guiden Executive Director The Arc Tennessee 545 Mainstream Drive, Suite 100 Nashville, TN 37228 1-800-835-7077 or 615-248-5878 ext. 14 cguiden@thearctn.org The Arc Tennessee does not discriminate based on race, color, national origin or Limited English Proficiency. If you feel you have been discriminated against please contact Peggy Cooper, Title VI coordinator, The Arc TN, 800-835-7077 ext. 15, pcooper@thearctn.org.   This e-mail may contain PRIVILEGED and CONFIDENTIAL information and is intended only for the use of the specific individual(s) to which it is addressed. If you are not an intended recipient of this e-mail, you are hereby notified that any unauthorized use, dissemination or copying of this e-mail or the information contained in it or attached to it is strictly prohibited. If you have received this e-mail in error, please delete it and immediately notify the person named above by reply mail. Thank you.    4 October 16, 2019 Mr. Gabe Roberts Deputy Commissioner Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Mr. Roberts, On behalf of The Arc Tennessee board, staff, and members, thank you for the opportunity to provide public comment on Amendment 42, a proposal that would convert a portion of the TennCare program to a block grant. The Arc Tennessee is a statewide advocacy organization for people with intellectual and developmental disabilities and their families. We have an affiliated network of fifteen local chapters throughout the state as well as an affiliation with our national office, The Arc of the United States. The Arc Tennessee opposes the conversion of the federal Medicaid program to a block grant, and we oppose the conversion of any portion of the TennCare program to a block grant. Governor Bill Lee has suggested that advocates “do not understand block grants,” and that we are misinformed about Amendment 42. On the contrary, advocates DO understand block grants. We DO understand Amendment 42. It is precisely because we understand both block grants and Amendment 42 that we oppose them. While Amendment 42 certainly attempts to lay out a convincing argument for conversion to a block grant by explaining all the money that Tennessee is “losing” to the federal government by operating TennCare so efficiently under its current 1115c waiver, what it fails to do is provide any substance related to how the money would be used to improve the overall health of Tennessee’s most vulnerable citizens. TennCare insures approximately 18% of the state’s most vulnerable populations. According to the Sycamore Institute, Tennessee ranks 45th out of the 50 states in overall health of its citizens, 46th in obesity, 45th in diabetes, and 45th in depression. Governor Lee, the state legislature, and TennCare cannot expect advocates to blindly accept a proposal that fails to provide any detail as to how the additional money would be used to improve the health of its 545 Mainstream Drive, Suite 100, Nashville, TN 37228 Phone 615-248-5878 - Toll free 800-835-7077 – Fax 615-248-5879 http://www.thearctn.org members or how to expand benefits to additional populations, especially since the proposal bears little evidence of taking into consideration the concerns of the various advocacy groups. Furthermore, Amendment 42 relies upon the premise that both TennCare and the federal government have the data systems and processes in place to actually implement the funding mechanisms proposed in an efficient and timely matter. Historically, TennCare does not have a strong track record related to data and payment systems. There were significant challenges with 1915c service payments when they were transitioned from DIDD to TennCare, and providers had difficulty getting reimbursed. TennCare did not have the necessary systems in place for online applications when the ACA became law and people had to use the marketplace instead. More recently, thousands of Tennessee children were reportedly disenrolled from TennCare even though they were still eligible – presumably due to errors in redetermination paperwork getting where it needed to be. This history suggests that there will be challenges implementing Amendment 42 that would negatively impact its members and providers of services. In addition to our general concerns, The Arc Tennessee and its members have many concerns about how Amendment 42 will impact Tennesseans with intellectual and developmental disabilities and their families. There are approximately 7,000 people with intellectual and developmental disabilities on the "referral list" for the Employment and Community First (ECF) CHOICES program. ECF CHOICES provides home and community-based (HCBS) long term services and supports (LTSS). There is nothing in Amendment 42 to suggest that this “referral list” will be addressed with the additional money that TennCare claims will be available through this proposal. Historically, block grant funding creates significant challenges to expanding services or to serving additional people. ECF CHOICES has demonstrated a level of success in providing cost effective services for young adults with I/DD exiting school, but without additional funding, ECF CHOICES will continue its pattern of only being able to support people with emergent need (crisis). With an aging population, people with I/DD will be at great risk when their families are no longer able to care for them and no services are in place. This pattern of service provision is NOT cost effective. Amendment 42 demonstrates no acknowledgement of this population nor the thousands of young adults with I/DD that will be graduating from our schools in the coming years. Amendment 42 requests that TennCare be exempt from future federal Medicaid mandates. This means that TennCare would be exempt from any federal mandate that, for example, requires a new service, coverage for a particular medication, or even coverage for a particular population. This means if the Centers for Medicare and Medicaid services ever made HCBS LTSS mandatory (change the institutional bias) that TennCare would be exempt from that change. For people with I/DD, this means they would lose out on a critical federal change that would positively impact their lives. Amendment 42 requests permission to shift to a commercial-style closed prescription drug formulary instead of having to cover all prescription medications included in the federal Medicaid drug rebate program. This move to a commercial-style closed prescription drug formulary means TennCare could significantly limit the prescriptions covered, in particular specialty medications that could benefit a discrete population of people. For people with I/DD in particular, especially those dually diagnosed with a co-occurring mental illness, they often do not respond to the medications in the same way as someone without an I/DD. For individuals with particularly challenging behavioral health needs, it is critical that they have access to the most cutting-edge medications available to help manage their conditions. A closed prescription drug formulary that only requires 1 drug per diagnosis will negatively impact the health and safety of this population. Amendment 42 requests TennCare be exempt from the federal Medicaid comparability mandate that requires covered benefits extend to all covered populations. Historically, people with I/DD have been a low priority with respect to covered services or expansion of HCBS LTSS. We are concerned that being exempt from the federal Medicaid comparability mandate will lead to people with I/DD struggling to access to the types of services they need even more than they struggle to now, which will adversely impact their health and safety. Amendment 42 requests that TennCare be exempt from reapplying to CMS or being re-evaluated by the federal government. No program should be exempt from some level of oversight by its funder. No state agency would presume its vendors/contractors be exempt from their oversight. Removal of any level of federal oversight for the TennCare program is particularly troubling for people with I/DD and their families. Federal oversight has traditionally been critical to protecting people with I/DD because states have not done the right thing for this population. It took the federal Justice Department’s lawsuits against the state’s Arlington and Cloverbottom Developmental Centers, and ongoing federal oversight, for Tennessee to begin offering community-based services for people with I/DD. The Americans with Disabilities Act (ADA) was and is necessary because states didn’t voluntarily make buildings accessible. The Individuals with Disabilities Education Act (IDEA) was and is necessary because states did not see the need to provide a free and appropriate public education to children with I/DD. While the federal government is far from perfect, its oversight is necessary to protect the rights of people with I/DD. Amendment 42 requests that TennCare be allowed to make changes to the benefits it provides, TennCare enrollment processes, and service delivery systems without federal government approval or oversight. Again, federal oversight has traditionally been critical to protecting people with I/DD. Without that additional level of oversight, TennCare has the ability to limit TennCare eligibility for people with I/DD who are a traditionally more expensive population to support. This population is an easy target if funding becomes tight. Lastly, while the new Katie Beckett program will not be included in the block grant for the first three years of operation, after that time, the funding needed for operations (whether or not enrollment is at full capacity) will be through the block grant. We are deeply concerned that eligibility for the Katie Beckett program will be restricted in the name of cost containment, and that children with complex disabilities and medical needs will be adversely impacted as a result. It is extremely difficult for The Arc Tennessee and its members to hear Tennessee brag about how much money Tennessee has saved with TennCare over the years, yet for nearly 20 years there has been 6,000-7,000 people with I/DD waiting for needed services. Though you mention in Amendment 42 about how TennCare’s efficiency has only benefited the federal government, you make no mention of how that money could have been used to address unmet needs if it had stayed in the program. It is also extremely difficult for us to hear Tennessee brag about how much money TennCare and the state have in their “rainy day” funds when we were the only state that did not have a true Katie Beckett program. It took the mobilization of hundreds of families who have children with complex disabilities and the work of disability advocacy organizations to pass a law requiring the creation of the program. It also took legislation to address the needs of aging caregivers who were caring for their adult children with I/DD. Again, disability advocacy organizations had to mobilize families to draw attention to this critical need. Only because a law was passed do people with I/DD living with caregivers aged 75 and older get access to HCBS LTSS before reaching an emergent (crisis) statusf We frequently hear from families of children and adults with I/DDwho experience difficulties getting needed services now even though they receive TennCare and ECF CHOICES benefits. Amendment 42 requests to do away with federal safeguards governing the MCOs, which includes ensuring that they have adequate provider networks, pay providers promptly, and use actuarially sound rates. If the provider network is a challenge now, what will the future hold when the block grant funding isn’t sufficient to meet the needs of this population and the provider pool shrinks even more? The Arc Tennessee, its members, and the disability community have been asked to blindly trust the state of Tennessee and TennCare to do what is right for people with I/DD. As we have demonstrated in this letter, history prevents it from even remotely being a possibility. We oppose Amendment 42 and any attempt to convert TennCare funding to a block grant. Thank you again for the opportunity to submit public comment on Amendment 42. Should you have any questions, you may reach me at cguiden@thearctn.org. Sincerely, Carrie Hobbs Guiden Executive Director Doria Panvini Public Policy Committee Chair Jonathan Reeve From: Sent: To: Subject: Attachments: Israel Cook Friday, October 18, 2019 2:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment on TennCare Waiver Amendment 42 From SisterReach TennCare Waiver Amendment 42 Comment From SisterReach.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern,     Please find attached SisterReach's comment on the TennCare Waiver Amendment 42. We appreciate the  opportunity to comment on the proposal. If you have any questions or concerns, please contact me at  israel@sisterreach.org.     Thank you,    Israel Cook     Pronouns: she, her, hers  If/When/How Reproductive Justice State Fellow  SisterReach  2725 Kirby Rd., Ste. 15  Memphis, TN 38119  901.614.9906  www.sisterreach.org    1 October 18, 2019 Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 via email to: public.notice.tenncare@tn.gov RE: TennCare Waiver Amendment 42 Dear Mr. Roberts On behalf of SisterReach, a Memphis-based organization fighting for the healthy lives of families in our communities, we are submitting the following comments in response to the public notice inviting public comments on proposed Waiver Amendment 42. We appreciate the opportunity to comment on Tennessee’s TennCare waiver. SisterReach strongly opposes Tennessee’s application and implementation of a Medicaid block grant. The proposed waiver would dramatically affect access to necessary health care for the nearly 1.4 million Tennesseans and the 250,000 Shelby County residents relying on Medicaid.1 Additionally, this would have a disproportionate impact on Black families, who make up 29 percent of Tennessee’s Medicaid beneficiaries.2 This would detrimentally impact the health, well-being, and economic security of communities of color, including women and LGBTQ individuals, who rely on Medicaid to maintain bodily autonomy and to live healthy lives. SisterReach, founded in October 2011, is a Memphis, Tennessee-based grassroots non-profit organization supporting the reproductive autonomy of women and teens of color, poor and rural women, LGBT+ and gender non-conforming people and their families through the framework of Reproductive Justice. Our mission is to empower our base to lead healthy lives, raise healthy families and live in healthy and sustainable communities. We provide community-centered, comprehensive reproductive and sexual health education to marginalized people and advocate on the local, regional, state and national levels for public policies that support the reproductive health and rights of all women, young people, and their families. Reproductive Justice is a human rights framework that centers a person's entire life’s circumstances to inform the best way to assist them in achieving optimum health and wellness. Under this framework, access to affordable health insurance is a human right that allows the most marginalized individuals and communities including children, women, seniors and persons with disabilities to live safe and healthy lives. Attempts to limit and deny access to necessary coverage violates this fundamental right. 1 Sam Stockard, “Cohen calls for federal administrator to reject Tennessee block grant proposal”, Daily Memphian (Sept. 19, 2019). Available at: https://dailymemphian.com/section/metrostate-government/article/7608/cohen-callsfor-federal-administrator-to-reje. 2 Kaiser Commission on Medicaid Facts, “Medicaid’s Role for Black Americans”, (May 2011). Available: https://www.kff.org/wp-content/uploads/2013/01/8188.pdf. 1 In Tennessee, Medicaid provides a wide range of health services for low income families and people who are living in poverty. Recent research in Memphis demonstrated that 1 in 3 people were living in poverty. Add a medical disparity to that number and people are faced with the consequence of life or death. Medicaid is essential for people accessing general health care, family planning services, pregnancy-related care and STI testing and treatment and maternal health care. Medicaid is essential for people accessing family planning services, pregnancyrelated care, and STI testing and treatment. Medicaid covers over half of all births in Tennessee including prenatal services, childbirth, and post-partum care as well as a wide range of health care services. Without this access, maternal morbidity rates, STI rates, unintended pregnancies and aging health issues will skyrocket. Under the proposed TennCare Waiver Amendment 45, Medicaid will illegally and drastically change, impacting the most vulnerable individuals in damaging ways. For more than 50 years, the federal government and states have shared Medicaid costs, based on actual state health care spending. As such, there is no reason why a block grant needs to be instituted in Tennessee. Harmful expected outcomes of the proposed waiver will be almost no federal oversight of TennCare, critical cuts will be made to various services provided by TennCare and Tennessee is likely to bear the responsibility of any TennCare overspending. The impact of a Medicaid block grant will be felt mostly by women, people of color, children, older adults, and people with disabilities. Specifically, those in Shelby County where Medicaid enrollees make up 26 percent of our county’s total population and 17.6 percent of TennCare enrollees.3 Statewide, children make up almost 50 percent of individuals covered through TennCare.4 There are 229,300 individuals with disabilities covered, 66,300 elderly individuals and 48,000 pregnant women.5 Coverage through TennCare is also essential for caretakers of children, individuals with disabilities and elderly individuals, providing individuals with affordable health care that is lifesaving and ensures that people have the ability to live independently and care for themselves and family members. The ability for Tennessee to manage federal money allocated to Medicaid expenses with almost no federal oversight removes critical safeguards for those dependent on Medicaid. Arguments that a Medicaid block grant will give Tennessee the flexibility to increase the efficiency of Medicaid spending and reduce Medicaid costs, are untested and unlikely to occur. Tennessee is the first state to try to request a Medicaid block grant. There is uncertainty about whether the block grant is even legal. Rather than restricting access to current Medicaid enrollees, Tennessee should expand Medicaid to other low-income individuals.6 3 Corrine S. Kennedy, “'I don't trust them to do the right thing.' Lee's TennCare block grant proposal not well received in Memphis”, Memphis Commnercial Appeal (October 15, 2019). Available at: https://www.commercialappeal.com/story/news/2019/10/15/tenncare-tennessee-medicaid-block-grant-plancriticized-memphis-shelby-county/3984323002/. 4 Division of TennCare, “TennCare Overview” (August 2019). Available at: https://www.tn.gov/content/dam/tn/tenncare/documents/TennCareOnePager.pdf. 5 Division of TennCare, “TennCare Overview” (August 2019). Available at: https://www.tn.gov/content/dam/tn/tenncare/documents/TennCareOnePager.pdf. 6 Hannah Katch, Judith Solomon, Aviva Aron-Dine, “Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries”, Center on Budget and Policy Priorities (Sept. 25, 2019). Available at: https://www.cbpp.org/research/health/tennessee-block-grant-proposal-threatens-care-for-medicaidbeneficiaries#_ftn3 2 Under the block grant, cuts to Medicaid spending can be made without federal approval or oversight. As the proposal indicates, important managed care changes, prescription drug access and funding to various healthcare resources will be made without following federal regulation or guidelines. The current proposal mentions alterations of managed care funding. Managed care makes up about 63% of Tennessee Medicaid spending, over half of Medicaid coverage in Tennessee.7 The proposal gives the state strong financial incentives to cut benefits and reduce enrollment. For example, Tennessee could restrict core services such as hospital and emergency care or cut services like physical therapy, hospice, and transplant coverage. Further, SisterReach opposes the block grant proposal because of the capped funding nature of the grant. A block grant would be a capped sum of money that would not cover any increases in Medicaid spending. Tennessee would be expected to cover the cost. Block grants do not consider changes in employment rates, STI and HIV transmission increases, natural disasters and other events that can alter Medicaid spending.8 Specifically, a recession, as well as the rise of opioid usage, and responses to the opioid crisis could increase Medicaid enrollment and spending that would not be funded by the grant from the federal government.9 Vulnerable populations who are more likely to be most affected by the above changes are the ones dependent on Medicaid. The block grant will directly impact the ability to access care and improve bodily autonomy and economic stability. 28% of Black women in Tennessee live in poverty.10 Living in poverty severally limits access to health insurance. Almost 100,000 people in Tennessee do not have access to health insurance.11 Lastly, the request for a block grant does nothing to expand Medicaid coverage in Tennessee. Since Tennessee refused to expand Medicaid in 2016, thousands of Tennesseans have been unable to access healthcare.12 The block grant does nothing to address the health disparities in Tennessee which affect the most vulnerable in our communities. Medicaid was created to increase access to healthcare for Americans without health insurance, to protect Americans and their families and ensure economic security for our country. Black women, families and children have the lowest rates of health insurance in the South. In 2016, the rate of uninsured Black residents in Tennessee was 15 percent compared to the national average of 12 percent.13 7 Kaiser Family Foundation, “Medicaid in Tennessee” (November 2018). Available at: http://files.kff.org/attachment/fact-sheet-medicaid-state-TN 8 The Center for Healthcare Strategies, “Medicaid in Memphis, Tennessee: A Snapshot” (May 2015). Available at: https://www.chcs.org/media/Memphis_Tenn1.pdf 9 Kristi L. Nelson, “TennCare shifts to coverage of longer-term opioid addiction treatment”, Knox News (April 3, 2019). Avalailable at: https://www.knoxnews.com/story/news/health/2019/04/03/opioid-addiction-tenncaremedication-assisted-therapy-suboxone-methadone/3288432002/ 10 U.S. Census Bureau, “2015 American Community Survey (ACS) 1-Year Estimates, Washington, DC: Census Bureau. 11 The Henry J. Kaiser Family Foundation, “Current Status of State Medicaid Expansion Decisions, (2017). 12 Louis Noriss, “Tennessee and the ACA’s Medicaid Expansion”, healthinsurance.org (September 19, 2019). Available at: https://www.healthinsurance.org/tennessee-medicaid/ 13 National Partners for Women and Families, “Black Women Experience Pervasive Disparities in Access to Health Insurance” (April 2019). Available at:http://www.nationalpartnership.org/our-work/resources/health-care/blackwomens-health-insurance-coverage.pdf 3 Tennessee was one of nine states that saw an increase in the number of unenrolled children.14 Medicaid reform must create more opportunities to ensure our most vulnerable communities, not provide more ways for the government to cut spending. For all the foregoing reasons, Tennessee’s block grant waiver should be denied. If approved, the Medicaid block grant would create more barriers and unnecessary burdens on low income communities across race, class and socio-economic status. Parents with low incomes would have to choose between accessing healthcare and providing other necessary resources for themselves and their families. This would have significant and widespread negative implications for individuals, families, and communities who already face myriad barriers to accessing insurance coverage and quality health care. This proposal undermines fundamental Reproductive Justice values and would ultimately push healthcare access out of reach for many of Tennessee’s most vulnerable communities. We appreciate the opportunity to submit comments on the TennCare Waiver Amendment 42. For further information, please do not hesitate to contact Israel Cook, Policy Fellow, at israel@sisterreach.org Sincerely, Cherisse Scott CEO and Founder SisterReach 2725 Kirby Rd Suite #15 Memphis, TN 38119 14 Christopher Colman, “How Tennessee Became an Outlier in the Rising Number of Uninsured Children and What Must Happen to Reverse the Trend”, Tennessee Justice Center (July 26, 2019). Available at: https://www.tnjustice.org/wp-content/uploads/2019/07/How-Tennessee-Became-an-Outlier-in-the-Rising-Numberof-Uninsured-Children-and-What-Must-Happen-to-Reverse-the-Trend-1.pdf. 4 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: cram125@epbfi.com Friday, October 18, 2019 5:19 PM PUBLICE NOTICE TENNCARE Rep Hakeem; Bowling, Holton [EXTERNAL] Tennessee Medicaid Block Grant Proposal Block Grant.Comments.28HCTF.101819.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Mr. Gabe Roberts: Good evening. Thank you for holding a Public Hearing in Chattanooga this week. Attached are the comments submitted by Rep. Hakeem's Healthcare Task Force to the Tennessee Medicaid Block Grant Proposal. Should you have any questions and/or need additional information, please email or call me at 423.619.0732. Thank you in advance. Best of health, Chris L. Ramsey, Sr. Chairman, 28th Healthcare Task Force 1 28th Legislative District HealthCare Task Force Comments – October 18, 2019 Submitted by: Chris Ramsey (Chairman) Looking over Amendment 42 Draft (Project No. 11-W-00151/4) *Hamilton County (2017) 32,303 residents were uninsured and most were working adults in low income homes. What is Tennessee’s current TennCare match rate? Public needs to know. *The 50/50 split with the Block Grant: The states “50%” need for mandatory reinvest into the program. “The state will have the flexibility to strategically invest block grant funds to support “rural” health transformation efforts.” What does this entail? Urban also continues to be underserved. The “cost” associated with any “new” population the state “opts” to cover in the future would be excluded from the block grant calculation for a period of years until the state “has enough” experience paying for services for “this population” to update the block grant formula in a financially sound manner. This seems to be addressing the immigrant population, which currently use emergency rooms heavily and no preventative care due to lack of services. Of the $7,858,874,398.00 this would be a “capped” grant, so this explains the above statement. Also, what about recessions (when people lose insurance), natural disasters, unplanned demands of public health emergencies? Page iii: States: No reductions in who is eligible for or what benefits are currently provided in TennCare---Please see page 20: Under Streamlining Unnecessary Approvals: “Federal Medicaid Policy distinguishes between mandatory Medicaid benefits (which states must make available to their members) and optional Medicaid benefits (which states may elect, at their discretion, to make available to their members). For both mandatory and optional benefits, states have flexibility to determine the amount, duration, and scope of covered benefits. *This is one reason TennCare “covers a far richer array of benefits” but if “the state proposes that it have the flexibility under this demonstration to make changes to its benefits package, including the addition or elimination of optional benefits and changes in the amount, duration, and scope of covered benefits, without the need for CMS approval”----These “richer array of benefits will go away. They also propose “The federal government cannot compel a state to cover an optional benefit, nor can it disapprove a state’s election to cover an optional benefit”. 1 They propose autonomy to adjust its package of covered benefits. They are proposing to exclude pharmacy cost from the block grant (outpatient prescription drugs). The exclusion of “specialty and orphan drugs” is reflected to new cancer drugs and other life-threatening medications. This would mean block grant would not pay for drugs and hospitals will close their cancer programs because they would not be able to provide care to the underserved/indigent. “State proposes that it have the flexibility to adopt a commercial-style closed formulary with at least ‘one’ drug available per therapeutic class”. Unfortunately, this will affect many in the community with chronic diseases. The “flexibility” to apply formulary management “tools” to help control cost of prescription drug benefit. This is leading down the path of “socialist” medicine where the state will dictate providers prescribing, and people served with the “block grant” coverage will receive substandard care. Although they mention the “wage index” and small community hospitals receive disproportionately low reimbursement from Medicare, the block grant will only continue disproportionately reimbursement because they have no plan in place. There are already practices and providers who do not take these programs because of payment model. What is the “block grant” model? Hospitals and private practices still do not have the “value care model” in place. Electronic Health Records (EMR) are costly to rural, small “nonprofit”, etc… 2 Jonathan Reeve From: Sent: To: Subject: Attachments: Cindy Snyder Friday, October 18, 2019 8:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on TennCare II Demonstration (Project No. 11-W-00151/4) - Amendment 42 ViiV Healthcare Comments - TennCare 1115 Waiver - Block Grant - October 2019 (Final).pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Re: TennCare II Demonstration (Project No. 11‐W‐00151/4) ‐ Amendment 42     Hello,  On behalf of ViiV Healthcare, the attached comments are submitted in response to the proposed “Amendment 42” to the TennCare II Demonstration. Please let me know if you have any questions. Thank you. Sincerely, Cindy Snyder Cindy Snyder Government Relations Director    ViiV Healthcare  5 Moore Drive, RTP, NC 27709‐3398 USA  Mobile:  919.323.9084  cindy.c.snyder@viivhealthcare.com  viivhealthcare.com   Twitter   Facebook      ViiV Healthcare monitors email communications sent to and from ViiV Healthcare in order to protect ViiV Healthcare,  our employees, customers, suppliers and business partners, from cyber threats and loss of ViiV Healthcare  Information. ViiV Healthcare monitoring is conducted with appropriate confidentiality controls and in accordance  with local laws and after appropriate consultation.  1 October 17, 2019 Via: public.notice.tenncare@tn.gov Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243. Re: TennCare II Demonstration (Project No. 11-W-00151/4) - Amendment 42 Dear Director Roberts; ViiV Healthcare (“ViiV”) appreciates the opportunity to submit comments to Tennessee’s Division of TennCare (“the Division”) regarding the proposed “Amendment 42” to the TennCare II Demonstration. ViiV is concerned that the proposed amendment will restrict necessary medications for people living with HIV (PLWH), resulting in harm to the health and wellbeing of PLWH in TennCare, and increased HIV transmission in the state. ViiV is the only independent, global specialist company devoted exclusively to delivering advancements in human immunodeficiency virus (HIV) treatment and prevention to support the needs of people living with HIV. From its inception in 2009, ViiV has had a singular focus to improve the health and quality of life of people affected by this disease and has worked to address significant gaps and unmet needs in HIV care. In collaboration with the HIV community, ViiV remains committed to developing meaningful treatment advances, improving access to its HIV medicines, and supporting the HIV community to facilitate enhanced care and treatment. As an exclusive manufacturer of HIV medicines, ViiV is proud of the scientific advances in the treatment of this disease. These advances have transformed HIV from a terminal illness to a manageable chronic condition. Effective HIV treatment can help PLWH to live longer, healthier lives, and has been shown to reduce HIV-related morbidity and mortality at all stages of HIV infection. 1, 2 Furthermore, effective HIV treatment can also prevent the transmission of the disease. 3 Despite groundbreaking treatments that have slowed the progression and burden of the disease, treatment of the disease is low – only half of PLWH are retained in medical care, according to the Centers for Disease Control and Prevention (CDC).4 More than 1.1 million people in the United States (U.S.) are living with HIV, and fifteen percent are unaware that they have the virus. 5 1 Severe P, Juste MA, Ambroise A, et al. Early versus standard antiretroviral therapy for HIV-infected adults in Haiti. N Engl J Med. Jul 15 2010;363(3):257-265. Available at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20647201 2 Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. Apr 30 2009;360(18):1815-1826. Available at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19339714 3 Roger et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. The Lancet. Published Online May 2, 2019 http://dx.doi.org/10.1016/S0140-6736(19)30418-0. 4 Understanding the HIV Care Continuum, CDC, https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf Accessed June 19, 2019 5 HIV in the United States: At a Glance, CDC, https://www.cdc.gov/hiv/statistics/overview/ataglance.html. Accessed June, 19, 2019. HIV in Tennessee As of 2017, there are approximately 19,300 people living with HIV in Tennessee.6 Tennessee now slightly exceeds the national average for viral load suppression (54 percent in Tennessee, versus 51 percent nationally).7 8 9 However, more needs to be done to ensure PLWH receive the care they need. For example, the state could still improve on engagement in medical care for those who have HIV. According to the Centers for Disease Control and Prevention (CDC), approximately 3000 people living with HIV in Tennessee are not getting the care they need.10 We commend the new efforts undertaken in the state to recognize and address the HIV epidemic in recent years. The City of Nashville's Ending the HIV Epidemic Plan11 was released in February 2019 by a task force12 of key stakeholders appointed by Mayor David Briley to oversee the creation of a 5-year plan to eliminate HIV/AIDS in the city. The plan was produced through an in-depth community planning process that included input from more than 120 individuals representing a cross sector of government representatives, advocates, service organizations, medical providers, academia, and communities of faith. This plan is an important step in the right direction, and we urge the Division to review the plan and consider how to incorporate these efforts more broadly throughout the whole state. The Tennessee Department of Health also has done excellent work in promoting HIV goals in the state by recognizing the links between the opioid epidemic and HIV transmission. In 2018, the Department of Health released the Tennessee Human Immunodeficiency Virus (HIV) & Hepatitis C Virus (HCV) Outbreak Response Plan,13 and worked with CDC officials to respond to the syndemics in the state. This plan is now shared by the CDC on its website, to help inform and guide other jurisdictions in similar efforts.14 The state of Tennessee has also taken on a new national importance in the fight against HIV. In 2019, President Trump announced his Administration’s goal to end the HIV epidemic in the U.S. within 10 years, and released the “Ending the HIV Epidemic: A Plan for America” which proposes to use scientific advances in antiretroviral therapy to treat PLWH, and expand proven models of effective HIV care and prevention. 15 The plan focuses its efforts to stop the HIV epidemic in top areas of HIV transmission in the U.S. Given its substantial HIV burden, Shelby County was identified as a location to receive new funding and additional resources as a part of the federal government’s Ending the HIV Epidemic initiative.16 17 The new federal Ending the HIV Epidemic strategy is to: diagnose early, employ effective antiretroviral treatment to achieve and maintain viral suppression, prevent new infections by utilizing pre-exposure prophylaxis (PrEP), and rapidly detect and respond to emerging clusters of HIV infections. 18 6 CDC, 2017 data. https://www.cdc.gov/hiv/pdf/policies/profiles/cdc-hiv-tennessee-SSP.pdf HIV Epidemiological Profile 2017 Tennessee Department of Health January 2019 https://www.tn.gov/content/dam/tn/health/program-areas/hiv/2017_HIV_Epi_Profile.pdf 8 Roger et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. The Lancet. Published Online May 2, 2019 http://dx.doi.org/10.1016/S0140-6736(19)30418-0. 9 Understanding the HIV Care Continuum, CDC, https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf Accessed June 19, 2019 10 CDC, 2017 data. https://www.cdc.gov/hiv/pdf/policies/profiles/cdc-hiv-tennessee-SSP.pdf 11The Metro Nashville Ending the Epidemic Plan https://www.nashville.gov/Portals/0/SiteContent/MayorsOffice/Health/docs/ending-theepidemic-plan.pdf.pdf 12 Ending the HIV/AIDS Epidemic in Nashville Task Force, https://www.nashville.gov/Mayors-Office/Health/Ending-the-Epidemic.aspx 13 Tennessee Human Immunodeficiency Virus (HIV) & Hepatitis C Virus (HCV) Outbreak Response Plan, 2018 https://www.cdc.gov/hiv/pdf/programresources/guidance/cluster-outbreak/cdc-hiv-hcv-pwid-response-plan.pdf 14Centers for Disease Control and Prevention, New CDC Resources: HIV & HCV Outbreak Detection and Response https://www.hhs.gov/hepatitis/blog/2018/04/06/new-cdc-resources-hiv-hcv-outbreak-detection-and-response.html 15 HIV.gov “Ending the HIV Epidemic” https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview Accessed July, 15, 2019. 16 Ending the HIV Epidemic: A Plan for America. https://files.hiv.gov/s3fs-public/Ending-the-HIV-Epidemic-Counties-and-Territories.pdf 17 HIV.gov “Ending the HIV Epidemic” https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview Accessed July, 15, 2019. 18 Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV Epidemic: A Plan for the United States. JAMA. 2019;321(9):844– 845. doi:10.1001/jama.2019.1343. 7Tennessee 2 HIV and Medicaid As a part of these city, state, and national efforts to end the HIV epidemic, it is imperative that state Medicaid programs also promote policies that contribute to HIV public health, such as preserving continuous access to comprehensive health care, including antiretroviral therapy (ART) for PLWH in order to improve health outcomes and reduce new transmissions. TennCare has an opportunity to align with state and federal efforts to end the HIV epidemic by maintaining a robust formulary of antiretrovirals and implementing an HIV viral load suppression quality measure. Medicaid has played a critical role in HIV care since the epidemic began. Medicaid is the largest source of coverage for people living with HIV.19 In fact, more than half of PLWH who are engaged in medical care have incomes at or below the federal poverty level. 20 Medicaid is an essential source of access to medical care and ART drug coverage for people living with HIV. This medical care and drug treatment not only preserves the health and wellness of PLWH and improves health outcomes, but it also prevents new HIV transmissions. Effective HIV Treatment HIV treatment is a dynamic area of scientific discovery, and treatment protocols are changed and updated to reflect advances in medical science. Thanks to these advancements, the scientific community has been able to focus on improving treatment regimens and care for PLWH, helping to reduce pill size and the number of pills required to a single, once-daily, fixed-dose tablet combining multiple drugs that suppress the virus. Today a person diagnosed with HIV who adheres to ART can expect to live a near normal life span.21 Strict adherence to (ART) – taking HIV medicines every day and exactly as prescribed – is essential to sustained suppression of the virus, reduced risk of drug resistance, and improved overall health. 22 The Health Resources and Services Administration (HRSA) states in its Guide for HIV/AIDS Clinical Care that “adherence to ART is the major factor in ensuring the virologic success of an initial regimen and is a significant determinant of survival.” 23 Nonadherence – or skipping HIV medicines – may lead to drugresistance, and reduce or eliminate the effectiveness of treatment with some HIV medicines.24 In fact, the World Health Organization (WHO) recently reported that resistance among people retained on ART ranged from four to 28 percent, while among people with unsuppressed viral load on first-line ART regimens, resistance ranged from 47 to 90 percent.25 Federal HIV clinical treatment guidelines (Department of Health and Human Services (DHHS) Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV) also emphasize the importance of adherence to ensure long-term treatment success.26 When a PLWH receives and maintains effective HIV treatment, they can reach viral suppression. Viral suppression means that the virus has been reduced to an undetectable level in the body with standard 19 Kaiser Family Foundation. Medicaid and HIV, http://www.kff.org/hivaids/fact-sheet/medicaid-and-hiv/. CDC, Behavioral and Clinical Characteristics of Persons Receiving Medical Care for HIV Infection—Medical Monitoring Project, United States, https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-hssr-mmp-2014.pdf 2014 cycle (June 2014-May 2015). Surv report 17 21 Samji H, et al. Closing the Gap: Increases in Life Expectancy among Treated HIV-Positive Individuals in the United States and Canada. PLoS One. 2013; 8(12): e81355. doi: 10.1371/journal.pone.0081355 22 AIDS info.gov, NIH, Following an HIV Regimen: Steps to Take Before and After Starting HIV Medicines, January 31, 2019 https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/21/55/following-an-hiv-regimen---steps-to-take-before-and-after-starting-hivmedicines 23 HRSA, Guide for HIV/AIDS Clinical Care (April 2014), https://hab.hrsa.gov/sites/default/files/hab/clinical-quality-management/2014guide.pdf. Accessed October 13, 2017. 24 AIDS Info, HIV Treatment Fact Sheet (March 2, 2017), https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/21/56/drug-resistance. Last accessed October 13, 2017. 25 WHO, HIV Drug Resistance Report 2017, http://apps.who.int/iris/bitstream/10665/255896/1/9789241512831-eng.pdf?ua=1. Accessed October 13, 2017. 26 DHHS Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, NIH.gov https://aidsinfo.nih.gov/guidelines Accessed on 6/26/2019 20 3 tests.27 Viral suppression results in reduced mortality and morbidity and leads to fewer costly medical interventions.28 HIV Treatment as Prevention Viral suppression also helps to prevent new transmissions of the virus. When successful treatment with an antiretroviral regimen results in virologic suppression, secondary HIV transmission to others is effectively eliminated. In studies sponsored by the National Institutes of Health (NIH), investigators have shown that when treating the HIV-positive partner with antiretroviral therapy, there were no linked infections observed when the HIV+ partner’s HIV viral load was below the limit of detection.29 The National Institute of Allergy and Infectious Diseases (NIAID) supported research that demonstrated when PLWH achieve and maintain viral suppression, there is effectively no risk scientifically of transmitting HIV to their HIV-negative sexual partner. 30 Multiple subsequent studies also showed that PLWH on ART who had undetectable HIV levels in their blood, had essentially no risk of passing the virus on to their HIVnegative partners sexually.31,32 As a result, the CDC estimates viral suppression effectiveness in preventing HIV transmission at 100 percent. 33 The scientific news that HIV treatment also offers the benefit of prevention of HIV transmission led to the development of a movement called “U=U” or Undetectable = Untransmittable. Backed by the scientific data, U=U reinforces the message that viral suppression can help end the HIV epidemic. 34 Today, the NIH, CDC and health authorities in many other countries have endorsed the U=U message.35, 36 The scientific success of U=U reaffirms the need for PLWH to have uninterrupted access to prescribed drug treatment and the ability to stay retained in care. Reduced transmissions not only improve public health, but also save money. The CDC estimates that PLWH in Tennessee face an average lifetime cost of $478,000 to treat HIV. 37 Therefore, preventing new transmissions offers a substantial fiscal benefit to the state. In studies sponsored by the National Institutes of Health (NIH), investigators have shown that when treating the HIV-positive partner with antiretroviral therapy, 38 there were no linked infections observed when the infected partner’s HIV viral load was below the limit of detection. Reduced transmissions not only improve public health, but also save money. It is estimated PLWH who are not retained in medical care may transmit the virus to an average of 5.3 additional people per 100-person years.39 Other studies estimate that each HIV positive patient may approach $338,400 in additional costs to the healthcare system over his or her National Institutes of Health (NIH) “Ten things to Know about HIV Suppression” https://www.niaid.nih.gov/news-events/10-things-know-abouthiv-suppression 28 “Retention in Care and Adherence to ART are Critical Elements of HIV Care Interventions,” Stricker, et al, AIDS and Behavior, October 2014, Volume 18, Supplement 5, pp 465–47,: https://link.springer.com/article/10.1007/s10461-013-0598-6 29 Rodger et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. The Lancet. Published Online May 2, 2019 http://dx.doi.org/10.1016/S0140-6736(19)30418-0 . 30 NIAID, https://www.niaid.nih.gov/news-events/undetectable-equals-untransmittable. Accessed August 1, 2018. 31 Bavinton, et al. The Opposites Attract Study of viral load, HIV treatment and HIV transmission in serodiscordant homosexual male couples: design and methods. BMC Public Health. 2014; 14: 917. doi: 10.1186/1471-2458-14-917 32 Prevention of HIV-1 infection with early antiretroviral therapy. Cohen, et. al; HPTN 052 Study Team. N Engl J Med. 2011 Aug 11;365(6):493505. 33 Centers for Disease Control and Prevention (CDC) “Effectiveness of Prevention Strategies to Reduce the Risk of Acquiring or Transmitting HIV” https://www.cdc.gov/hiv/risk/estimates/preventionstrategies.html Accessed September 20, 2019. 34 https://docs.wixstatic.com/ugd/de0404_6739336ddf8047799bda35e3f58aed77.pdf 35 “Effectiveness of Prevention Strategies to Reduce the Risk of Acquiring or Transmitting HIV,” CDC, https://www.cdc.gov/hiv/risk/estimates/preventionstrategies.html 36 “For HIV, Treatment is Prevention” Dr. Francis Collins, NIH Director’s Blog, posted January 22nd, 2019 https://directorsblog.nih.gov/2019/01/22/for-hiv-treatment-is-prevention/ 37 CDC, 2017 data https://www.cdc.gov/hiv/pdf/policies/profiles/cdc-hiv-tennessee-SSP.pdf 38 Roger et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. The Lancet. Published Online May 2, 2019 http://dx.doi.org/10.1016/S0140-6736(19)30418-0. 39 Skarbinski, et al. JAMA Intern Med. 2015;175(4):588-596. 27 4 lifetime even if diagnosed early and retained in care.40 Successful treatment with an antiretroviral regimen results in virologic suppression and virtually eliminates secondary HIV transmission to others. As a result, it is possible to extrapolate that successful HIV treatment and medical care of each infected patient may save the system up to $1.79 million by preventing41 further transmission to others. These savings can only occur, however, if PLWH are diagnosed, have access to medical care, receive treatment, and remain adherent to their prescribed therapy. Proposed TennCare Waiver Due to the important role of TennCare in ensuring access to medical care and treatment for PLWH in the state of Tennessee, ViiV wishes to comment on several of the proposals in the draft amendment42 that are likely to impact the health and wellbeing of PLWH in TennCare. 1. Open Formulary for HIV In Tennessee’s draft amendment, the state requests to “have the flexibility under this demonstration to adopt a commercial-style closed formulary with at least one drug available per therapeutic class.” 43 Under the Medicaid Drug Rebate Statute, drug manufacturers pay rebates on Medicaid utilization of their products in return for state Medicaid programs covering their products, subject only to certain “permissible restrictions” listed in the statute.44, 45 Tennessee proposes to waive these coverage requirements by establishing a closed formulary that would include at least one drug in each therapeutic class. This does not comply with the rebate statute’s more patient‐protective formulary standards. The case PhRMA v. Thompson held that the statute (SSA § 1115) does not authorize waivers of the Medicaid Drug Rebate Statute.46 Even if a waiver of the rebate statute were permitted, waiving its coverage requirements alone (without waiving the requirements for manufactures to pay rebates) would violate the legislative bargain reflected in the rebate statute. As CMS has explained: [The Medicaid rebate statute] sets forth requirements for covered outpatient drugs, whereby drug manufacturers must pay statutorily‐defined rebates to the states through the Medicaid drug rebate program. In return, any state that provides payment for drugs must cover all covered outpatient drugs, which may include appropriate limitations on amount, duration, and scope, for the drug manufacturers that participate in the Medicaid drug rebate program.47 The rebate statute’s legislative history48 also emphasizes that the statute links manufacturer rebate obligations and Medicaid coverage obligations. Congress required states to cover all products of a manufacturer with a Medicaid rebate agreement (with specified exceptions), to ensure beneficiary access to the full range of drugs that are available to private patients. The statute purposely coupled the rebate requirements on manufacturers with the coverage requirements on states; it was described by Congressman Henry Waxman, a key sponsor, as a “government‐industry compact.”49 Thus, TennCare cannot retain the mandatory rebate for some classes and have a closed formulary for others. For further indications of this, we urge the state to review the decision CMS made in response to a similar proposal from Massachusetts in 2018. 50 40 Schackman BR, Fleishman JA, Su AE, Berkowitz BK, Moore RD, Walensky RP, et al. The lifetime medical cost savings from preventing HIV in the United States. Medical care. 2015;53(4):293–301, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359630/ 41 Schackman BR, Fleishman JA, Su AE, Berkowitz BK, Moore RD, Walensky RP, et al. The lifetime medical cost savings from preventing HIV in the United States. Medical care. 2015;53(4):293–301, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359630/ 42 TennCare II Demonstration, Project No. 11-W-00151/4, Amendment 42, DRAFT: https://www.tn.gov/content/dam/tn/tenncare/documents2/TennCareAmendment42.pdf 43 TennCare II Demonstration, Project No. 11-W-00151/4, Amendment 42, DRAFT: https://www.tn.gov/content/dam/tn/tenncare/documents2/TennCareAmendment42.pdf 44 SSA § 1927(d)(1)(B)) 45 Medicaid rebate statute, codified at 42 U.S.C. § 1396r‐8 46 PhRMA v. Thompson, 251 F.3d 219, 222 (D.C. Cir. 2001) 47 78 Fed. Reg. 4594, 4631 (Jan. 22, 2013) 48 H. Rpt. 101‐881, 101st Congress, 2d Session (Oct. 16, 1990 49Medicare and Medicaid Reconciliation: Hearings Before the Subcomm. on Health and the Environment of the Committee on Energy and Com merce, H. Hrg. 103‐61, 103rd Cong. 453 (1993) (statement of Rep. Waxman). 50 CMS letter to Daniel Tsai, Assistant Secretary, MassHealth, June 27, 2008 5 In addition to the problems this proposal poses under the Medicaid drug rebate statute in general, proposals related to closed formularies or to therapeutic drug class limitations are specifically problematic for HIV treatment and for PLWH. As previously stated, prescription drug treatment is essential to PLWH, to effectively manage a deadly virus, to extend health and wellness, and to prevent transmission. The standard for HIV treatment is combination ART, and many regimens are available as a once-per-day single tablet regimen (STR). These STRs do not represent a single drug class, but fall into several therapeutic classes based on their formulation. If the state moves to a low-threshold of coverage of only one drug per class, that could mean that some or most STRs might become unavailable to PLWH. This is problematic for two reasons: • First, taking multiple pills per day reduces adherence, which is a crucial component of effectiveness in HIV treatment and in reaching viral suppression. Studies comparing the use of a single-tablet regimen (STR) versus a multi-tablet regimen (MTR) in PLWH across government sponsored plans, such as Medicaid, compared to commercially insured enrollees showed that more people in Medicaid are using a MTR.51, 52 However, studies have also shown the adherence rates for people on a STR are consistently higher than those on a MTR. 53 Analyses have shown that those on a STR had fewer hospitalizations and lower overall health care costs. A recent analysis published by Express Scripts reported people living with HIV enrolled in a government sponsored health plan were more likely to use a MTR than those enrolled in commercial insurance.54 However, adherence was higher in the STR users as compared to the MTR users.55 For all health plan types evaluated, those on a MTR had higher health care costs regardless of their adherence status but the difference was greater for those adherent to a STR which was $5,427 less than a patient adherent to a MTR.56 • Second, HIV treatments are not one-size fits all, and often ART options cannot be easily substituted. Health care providers work closely with patients to select HIV treatment options with great specificity for each patient. PLWH often face a variety of medical challenges that impede access to, retention in, and adherence to HIV care and treatment. PLWH rely on open formularies because the effective treatment of HIV is highly individualized and accounts for a patient’s size, gender, treatment history, viral resistance, coexisting illnesses, drug interactions, immune status, and side effects. In fact, the HHS clinical treatment guidelines57 state that, “[g]iven the wide array of treatment options, individualizing treatment with patient involvement in decision making is the cornerstone of treatment planning and therapeutic success.”58 The guidelines also recognize that “[i]t is important to consider the patient’s daily schedule; patient tolerance of pill number, size and frequency; and any issues affecting absorption.”59 Patients often respond differently to the same drug. Even drugs in the same class can have different side-effect profiles, with some patients best suited to one particular drug. Medical challenges for PLWH also include an increased risk for, and prevalence of, comorbidities that require additional drug treatment such as depression and substance use disorders, 60 as well as cardiovascular disease, hepatic and renal disease, osteoporosis, metabolic disorders, and 51 Express Scripts. Viral Signs: U.S. trends in HIV medication use, care and cost. November 2018. http://lab.expressscripts.com/lab/publications/viral-signs-understanding-hiv-medication-use. 52 Kangethe A, et al. Real-world health plan data analysis: Key trends in medication adherence and overall costs in patients with HIV. JMCP. Vol 25(1), January 2019. Pp 88-93. 53 Id 54 Express Scripts. Viral Signs: U.S. trends in HIV medication use, care and cost. November 2018. http://lab.expressscripts.com/lab/publications/viral-signs-understanding-hiv-medication-use. 55 Id 56 Id 57 DHHS Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, NIH.gov https://aidsinfo.nih.gov/guidelines Accessed on 6/26/2019 58 HHS, Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, p. 183, https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0. Accessed October 13, 2017. 59 Id. 60 CDC, Medical Monitoring Project, United States, 2013 Cycle (June 2013–May 2014 6 several non–AIDS-defining cancers. 61,62,63 The most common non-infectious co-morbidities of HIV are hypertension, hyperlipidemia, and endocrine disease. 64 Thus, PLWH must have access to a robust formulary that provides physicians with the ability to prescribe the right treatments at the right time for their patients. Aging PLWH often experience non-HIV related comorbidities65 that require polypharmacy which can increase risk for drug-drug interactions. In 2016, nearly half of people in the U.S. living with diagnosed HIV were aged 50 and older. 66 Polypharmacy is common in older patients with HIV; therefore, there is a greater risk of drug-drug interactions between antiretroviral drugs and concomitant medications. Clinically significant drug interactions have been reported in 27 to 40 percent of HIV patients taking antiretroviral therapy requiring regimen changes or dose modifications.67 Potential for drug-drug interactions should be assessed regularly, especially when starting or switching antiretroviral therapy and concomitant medications.”68 The U.S. DHHS even stressed the importance of covering all FDA approved drugs, including ART for PLWH, in its December 1, 2016 Informational Bulletin entitled Opportunities to Improve HIV Prevention and Care Delivery to Medicaid and CHIP Beneficiaries: Given that adherence to ART is a critical prerequisite to realizing both individual and public health benefits, states are reminded of the statutory requirement to cover all covered outpatient drugs of manufacturers with agreements described section 1927(b) of the Act, including single tablet ART regimens. States can also, and are strongly encouraged to, go farther to support access and adherence to effective treatments for PLWH. States should design their prescription drug formularies to minimize potential barriers presented by utilization management techniques so that Medicaid and CHIP beneficiaries living with HIV can readily access all regimens described for potential use (including those labeled as “Recommended”, “Alternative”, and “Other”) in the DHHS Guidelines. 69 Accordingly, it is critical that HIV+ persons in TennCare have access to all ART rather than limiting access through a closed formulary. Studies show that restricting access to drugs through closed formularies results in non‐adherence or poor adherence to prescribed medication regimens, worsened health outcomes, and higher, long‐run costs, both to Medicaid and other state and local programs.70, 71 Additionally, we urge TennCare to avoid clinical coverage policies that could restrict access to drugs/classes for populations that have a high need for adherence to see optimal medical benefit, such as with HIV medicines. We urge the state to avoid utilization management measures in the antiretroviral 61 Joel Gallant, Priscilla Y Hsue, Sanatan Shreay, Nicole Meyer; Comorbidities Among US Patients With Prevalent HIV Infection—A Trend Analysis, The Journal of Infectious Diseases, Volume 216, Issue 12, 19 December 2017, Pages 1525–1533, https://doi.org/10.1093/infdis/jix518 62 Rodriguez-Penney, Alan T. et al. “Co-Morbidities in Persons Infected with HIV: Increased Burden with Older Age and Negative Effects on Health-Related Quality of Life.” AIDS Patient Care and STDs 27.1 (2013): 5–16. PMC. Web. 21 June 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3545369/ 63 Joint HHS, CMCS, HRSA, and CDC Informational Bulletin, Opportunities to Improve HIV Prevention and Care Delivery to Medicaid and CHIP Beneficiaries, p. 9 (December 1, 2016), https://www.medicaid.gov/federal-policy-guidance/downloads/cib120116.pdf. Accessed October 13, 2017.. 64 Joel Gallant, Priscilla Y Hsue, Sanatan Shreay, Nicole Meyer; Comorbidities Among US Patients With Prevalent HIV Infection—A Trend Analysis, The Journal of Infectious Diseases, Volume 216, Issue 12, 19 December 2017, Pages 1525–1533, https://doi.org/10.1093/infdis/jix518 65 Schouten J, et al. Clin Infect Dis. 2014 Dec 15;59(12):1787-97. 66 “HIV and Older Americans,” CDC, https://www.cdc.gov/hiv/group/age/olderamericans/index.html 67 Evans-Jones JG et al. Clin Infect Dis 2010;50:1419–1421; Marzolini C et al. Antivir Ther 2010;15:413–423. 68 DHHS guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. May 30, 2018. Accessible at https://aidsinfo.nih.gov/guidelines (accessed June 2018) 69 Joint HHS, CMCS, HRSA, and CDC Informational Bulletin, Opportunities to Improve HIV Prevention and Care Delivery to Medicaid and CHIP Beneficiaries, p. 12 (December 1, 2016), https://www.medicaid.gov/federal-policy-guidance/downloads/cib120116.pdf. Accessed October 13, 2017. 70 Happe LE, Clark D, Holliday E, Young T. A systematic literature review assessing the directional impact of managed care formulary restrictions on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization. J Manag Care Spec Pharm. 2014;20(7):677‐84. 71 Zullig, LL, Bosworth, H, Engaging patients to optimize medication adherence. NEJM Catalyst, May 14, 2017. 7 drug class. Prior authorization requirements impact provider efficiency and increase costs of care. 72, 73 The historic lack of uniformity between health plans’ and insurers’ prior authorization processes results in providers spending excessive amounts of time completing prior authorization forms, negotiating administrative systems and spending less time on patient care. 74 More importantly, restricting access to HIV treatment for Medicaid beneficiaries with HIV may have permanent consequences for future treatment options. Prior authorization processes lead to patients experiencing delays in receiving their medications, which can negatively impact patient adherence – a vital component of effective HIV treatment. In a study, PLWH who faced drug benefit design changes were found to be nearly six times more likely to face treatment interruptions than those with more stable coverage, which can increase virologic rebound, drug resistance, and increased morbidity and mortality.75 2. Block Grant ViiV opposes the state’s proposal to institute a block grant to finance the TennCare program. The waiver proposes to cap federal spending for most eligible populations, and the state hypothesizes that, “TennCare expenditures under this demonstration will grow at a slower rate than the average Medicaid expenditures nationally.”76 We appreciate that the current intent is not to limit eligibility or benefits, however, we are concerned that this proposal creates significant likelihood for necessitated future reductions in coverage and benefits that would have a profoundly negative impact on vulnerable patient populations like PLWH. Although we understand the state’s desire to create fiscal stability in the TennCare program, caps or reductions in benefits such as medical care and drug treatment, would not result in budgetary benefit in the case of beneficiaries living with HIV, quite the opposite. These restrictions are likely to have a two-fold negative consequence of decreased health and increased overall health costs for PLWH, and also increased HIV transmission in the state.77 Furthermore, access to qualified medical care providers is important for PLWH in order to monitor disease progression and ensure viral suppression is maintained. 78 79 Access to infectious disease specialists and HIV-specialized providers80 is vital for PLWH, as HIV patients see better outcomes, and receive more cost-effective care when treated by an experienced HIV provider.81 As previously stated, prescription drug treatment is essential to PLWH, to effectively manage a deadly virus, to extend health and wellness, and to prevent transmission. Tennessee’s draft amendment refers to “outpatient prescription drugs” as being excluded from the block grant, but does not define this term. We encourage the state to align this definition with the Medicaid Drug Rebate definition for “covered outpatient drugs,” as defined by Section 1927 of the Social Security Act.82 72 Health Affairs “What does it cost physician practices to interact with health insurance plans?” 2009 http://content.healthaffairs.org/content/28/4/w533.abstract?ijkey=ab6e6c7d689c5a4949c03fc849458f04aeb59a2d&keytype2=tf_ipsecsha 73 Oxford Journal of Clinical Infectious Diseases “Uncompensated Medical Provider Costs Associated with Prior Authorization for Prescription Medications in an HIV Clinic” Vol. 51 Issue 6, 2010 http://cid.oxfordjournals.org/content/51/6/718.abstract 74 Health Affairs “US physician practices versus Canadians: spending nearly four times as much money interacting with payers. 2011 http://content.healthaffairs.org/content/30/8/1443.abstract?ijkey=702ae6e197f5830f7a20cd1ac2a80f693306073f&keytype2=tf_ipsecsha 75 Das-Douglas, Moupali, et al. "Implementation of the Medicare Part D prescription drug benefit is associated with antiretroviral therapy interruptions." AIDS and Behavior 13.1 (2009): 1 76 TennCare II Demonstration, Project No. 11-W-00151/4, Amendment 42, DRAFT: https://www.tn.gov/content/dam/tn/tenncare/documents2/TennCareAmendment42.pdf 77 Schackman BR, Fleishman JA, Su AE, Berkowitz BK, Moore RD, Walensky RP, et al. The lifetime medical cost savings from preventing HIV in the United States. Medical care. 2015;53(4):293–301, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359630/ 78 Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. Physicians’ experience with the acquired immunodeficiency syndrome as a factor in patients’ survival. New Engl J Med. 1996;334:701–7. [PubMed] 79 Gallant, Joel E. et al. “Essential Components of Effective HIV Care: A Policy Paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition.” Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America53.11 (2011): 1043–1050. PMC. Web. 20 Dec. 2017. 80 Identifying Providers Qualified to Manage the Longitudinal Treatment of Patients with HIV Infection and Resources to Support Quality HIV Care Revised: March 2013, HIV Medicine Association https://www.hivma.org/globalassets/hivma/logos/revised-qualified-hiv-provider-policystatement-approved-3-16-13-1.pdf 81 Gallant, et al. Essential Components of Effective HIV Care. Clinical Infectious Diseases. 2011 Dec; 53(11):1043-50 82 Section 1927 of the Social Security Act, SSA.gov http://www.ssa.gov/OP_Home/ssact/title19/1927.htm 8 We also request that if significant changes to this waiver proposal, or block grant proposal in the course of working with the Center for Medicaid Services (CMS), that the state provide opportunity for additional public comments on the revised proposals before they are finalized or implemented. As the first state to propose such a significant change to the financing of its Medicaid program, we believe it is important to have a robust public debate about the potential impact of this proposal. 3. Demonstration Evaluation and Viral Load Suppression (VLS) Data Section 1115 of the Social Security statute allows for “Demonstration Waivers” in Medicaid. The Affordable Care Act law implemented new evaluation requirements for these waivers, including that states must have a publicly available, approved evaluation strategy. 83 States are required to explain the hypothesis they are testing through a waiver and submit quarterly or annual reports to HHS that describe the changes occurring under the waiver and their impact on access, quality, and outcomes.84 85 The waiver proposal states that one hypothesis of the State is “The demonstration will not negatively impact access to care or health outcomes for TennCare members,” and that the State’s methodology in assessing this hypothesis will involve “Comparison of key access and health outcome measures prior to implementation of the demonstration and during the demonstration,” using provider participation and access data, as well as “key health outcome metrics.” ViiV urges the State to report on the viral load suppression (VLS) outcome measure, as one of the key health outcomes metrics that will be used to assess the effectiveness of the program. VLS is a metric in the Adult Medicaid Core Set, and an important measure of patient health outcomes in HIV. As of 2017, Tennessee is slightly above the national average for viral load suppression (54 percent in Tennessee, 86 versus 51 percent nationally).87 The TennCare Episodes of Care included HIV as one of the 27 episodes in the 2018 performance period.88 The published results from the 2018 Performance Period showed that out of a total of 33 quality metrics tied to gain-sharing, HIV was one of the 10 metrics that improved in the state. ViiV believes that it is critically important to ensure that state Medicaid programs advance high-quality care for PLWH by tracking and publicly-reporting on viral load suppression. The use of HIV-related quality measures helps support adherence to current federal DHHS HIV ARV clinical guidelines. Whether or not this waiver is implemented, we encourage the state to use VLS as a TennCare quality measure as a means of improving focus on HIV quality, both in the state, and nationally. Tracking and reporting measures from the Adult Medicaid Core Set will help to ensure their future inclusion on the CMS Medicaid Scorecard.89 The scorecard reports on measures from the set utilized by at least twenty-five states, and the inclusion of HIV measures will encourage greater transparency and accountability for all state Medicaid programs in caring for PLWH. 83 Robin Rudowitz, MaryBeth Musumeci, and Alexandra Gates, Medicaid Expansion Waivers: What Will We Learn? (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2016), https://www.kff.org/medicaid/issue-brief/medicaid-expansion-waivers-what-willwe-learn/ 84 Robin Rudowitz, MaryBeth Musumeci, and Alexandra Gates, Medicaid Expansion Waivers: What Will We Learn? (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2016), https://www.kff.org/medicaid/issue-brief/medicaid-expansion-waivers-what-willwe-learn/ 85 The November 6, 2017 CMCS Information Bulletin (found at: https://www.medicaid.gov/federal-policy-guidance/downloads/cib1106172.pdf) on Section 1115 demonstration process improvements also signaled CMS’s interest in moving toward reducing the frequency of reporting required for states to semi-annually or annually for certain demonstrations. 86Tennessee HIV Epidemiological Profile 2017 Tennessee Department of Health January 2019 https://www.tn.gov/content/dam/tn/health/program-areas/hiv/2017_HIV_Epi_Profile.pdf 87 CDC, 2017 data. https://www.cdc.gov/hiv/pdf/policies/profiles/cdc-hiv-tennessee-SSP.pdf 88 2018 Episodes of Care Results, Division of TennCare https://www.tn.gov/content/dam/tn/tenncare/documents2/EpisodesOfCare2018PerformancePeriod.pdf 89 Medicaid & CHIP Scorecard, The Centers for Medicare & Medicaid Services (CMS), https://www.medicaid.gov/stateoverviews/scorecard/index.html Accessed October 1, 2019 9 According to CMS, in FY2017, six states reported on the viral load suppression measure through the Medicaid Adult Core Measure Set; Delaware, Louisiana, Nevada, New York, Rhode Island and Texas.90 91 Several state Medicaid programs have linked HIV quality measures to Managed Care performance, thus incentivizing health plans to achieve viral suppression for their PLWH. This has been demonstrated in the New York Ending the Epidemic plan, where now all Managed Care Organizations (MCOs) are reporting on VLS. Louisiana is another model state, linking performance to quality care. Louisiana’s Medicaid managed care program, Bayou Health, has included the HIV VLS outcome measure in its contracts with MCOs. To further drive improvement, MCOs have incorporated resources from the Louisiana Office of Public Health’s (OPH) STD/HIV Program into disease management programs after the state added measures to their contracts. As a result, the MCOs continue to support VLS goals that far exceed the national average.92 The state of Louisiana recently announced that fewer people have been diagnosed with an HIV infection in the past year than in any of the previous decade, less than 1000 new infections for the first time since 2005. 93 The state has a viral load suppression rate of 83 percent of PLWH in care. 94 We wish to urge TennCare to include the HIV VLS measure as a key access and health outcome measure, and closely monitor the impact of this draft amendment proposal to the PLWH population within this program. Conclusion ViiV Healthcare looks forward to working with the state and other stakeholders to ensure that Tennessee’s public programs continue to ensure that people living with HIV have access to quality care and to improved health outcomes. Please feel free to contact me at Cindy.c.snyder@viivhealthcare.com should you have any questions. Sincerely, Cindy Snyder Government Relations Director ViiV Healthcare 90 Quality of Care for Adults in Medicaid: Findings from the 2017 Adult Core Set https://www.medicaid.gov/medicaid/quality-ofcare/downloads/performance-measurement/2018-adult-chart-pack.pdf 91 “Quality of Care for Adults in Medicaid: Findings from the 2018 Adult Core Set, Chart Pack” September 2019 https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-adult-chart-pack.pdf Accessed October 8, 2019 92 Financing HIV Prevention Services. NASTAD. February 2016. 93 Louisiana Department of Health “HIV cases in Louisiana drop to lowest in more than a decade,” July 02, 2019, http://ldh.la.gov/index.cfm/newsroom/detail/5188 94 “Utilizing Medicaid Claims Data to Improve HIV Outcomes,” Gruber, Presentation, 2018 National Ryan White Conference, https://targethiv.org/sites/default/files/supporting-files/12379_Klein_508.pdf 10 Jonathan Reeve From: Sent: To: Subject: Attachments: Darrel Thompson Thursday, October 17, 2019 5:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments from CLASP on TennCare II Demonstration waiver 2019_clasptnwaivercomments.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Director Gabe Roberts,    Attached are comments from the Center for Law and Social Policy (CLASP) on the proposed amendment to the TennCare  II Demonstration waiver.    Best regards,  Darrel Thompson  Research Assistant, Income and Work Supports  Center for Law and Social Policy (CLASP)   1200 18th Street NW, Suite 200, Washington, D.C.   (202) 809‐9116   dthompson@clasp.org     1 October 17, 2019 Electronically submitted to public.notice.tenncare@tn.gov Re: Amendment 42 To Gabe Roberts, Director: The Center for Law and Social Policy (CLASP) appreciates the opportunity to comment on Tennessee’s proposed amendment (Amendment 42) to the TennCare II Demonstration waiver. CLASP is a national, nonpartisan, antipoverty nonprofit advancing policy solutions for low-income people. We work at both the federal and state levels, supporting policy and practice that makes a difference in the lives of people living in conditions of poverty. CLASP has reviewed the proposed amendment to the TennCare II Demonstration waiver and has serious concerns about the proposal’s impact on the Medicaid eligible population in Tennessee. These comments draw on CLASP’s experience in working with six states under the Work Support Strategies project, where these states sought to dramatically improve the delivery of key work support benefits to lowincome families, including health coverage, nutrition benefits, and child care subsidies through more effective, streamlined, and integrated approaches. From this work, we learned that the processes and practices that states use in the application and renewal processes are as fundamental to enrollment as the eligibility parameters. These comments also draw upon CLASP’s deep experience with the Temporary Assistance for Needy Families (TANF) block grant and the Child Care and Development Block Grant (CCDBG), which have demonstrated the effects of capped funding on eligibility, reimbursements, and administrative processes. Medicaid plays a critical role in supporting the health and well-being of low-income adults and children. Many work in low-wage jobs where employer-sponsored health care is not offered or is prohibitively expensive. In fact, only 16 percent of poor adults receive health insurance through their jobs1 and, according to a recent survey by the Bureau of Labor Statistics, low-wage workers pay more for employer-provided medical care benefits than higher-wage workers.2 Others may have health concerns that threaten employment stability, and without Medicaid, would be denied access to the medical supports they need to hold a job, such as access to critical medications. The Medicaid statute is clear that the purpose of the program is to furnish medical assistance to individuals whose incomes are not enough to meet the costs of necessary medical care and to furnish such assistance and services to help these individuals attain or retain the capacity for independence and self-care. States are allowed in limited circumstances to request to “waive” provisions of the rule but the Secretary of Health and Human Services (HHS) may only approve a project which is “likely to assist in promoting the objectives” of the Medicaid Act.3 A waiver that does not promote the provision of health care would not be permissible. In the proposed amendment Tennessee is requesting sweeping changes to both the financing and federal oversight of the Medicaid programs. If approved by CMS, this proposal would negatively affect the Medicaid eligible population in Tennessee. In addition to our specific concerns below, CLASP believes the core content of this waiver proposal is not compatible with the waiver authority granted through Section 1115 waivers. A 1200 18th Street NW, Suite 200 • Washington, D.C. 20036 • (202) 906-8000 • clasp.org complete restructuring of Medicaid financing and a lack of any federal oversight on Medicaid spending and enrollment changes are not allowable through Section 1115 waivers.4 Tennessee’s proposal to receive fifty percent of any federal dollars that are not spent in a given year provides the state with a clear incentive to underspend the federal block grant. Underspending federal dollars in order for the state to receive half of the unspent federal dollars would likely be achieved in several ways. For example, lowering reimbursement rates for providers, eliminating benefits, or changing application and enrollment processes in ways that lead to reduced enrollment. Specifically, our concerns include eligibility and enrollment, diverting dollars from health care, member penalties and lock-out periods, and more clarity needed for the dual eligible population. Eligibility and enrollment The proposed amendment clearly states that Tennessee is not requesting to change or reduce eligibility for Medicaid, but the provisions requested within the amendment are highly likely to lead to reduced enrollment. The combination of the proposed financing agreements and lack of oversight by CMS to enrollment policies causes CLASP to believe that access to Medicaid will be diminished. Tennessee’s request to have unilateral ability to change enrollment processes, service delivery systems, and comparable program elements without seeking additional CMS approvals via State Plan Amendments or demonstration amendments is highly problematic. Without further understanding of what Tennessee intends to change with regard to enrollment processes and service delivery systems, our concern is that the state will act to make the processes more cumbersome and difficult for beneficiaries. This could be done by increasing verifications, adding paperwork to the process, or requesting more frequent checks of eligibility – all of which make it more likely that someone will either not complete the enrollment process or will become unenrolled due to paperwork barriers during their certification period. There is strong evidence that such processes can have significant impacts on program participation, without any "eligibility" changes.5 Furthermore, because Tennessee is proposing to exempt administrative costs from the block grant, the state would not have an incentive to keep administrative costs low, meaning there would be no incentive to keep paperwork and other verifications at a minimum. Under the waiver proposal, Tennessee could spend a dollar in increased administrative costs to save a dollar in medical costs, and claim a share of the "savings." This is both a huge waste of public resources and a clear violation of the cost neutrality requirement for waivers. Together, the incentive to underspend federal dollars combined with the request to make any changes to enrollment processes without federal oversight is a recipe for the state to make enrollment and renewal more difficult as a means to reducing participation and spending fewer dollars on Medicaid. Diverting dollars from health care Tennessee’s proposal to use federal Medicaid dollars for services not directly related to health care raises concerns that dollars will be diverted from providing health care – the core purpose of Medicaid – to other unknown expenditures. While CLASP acknowledges that social determinants of health play a large role in a person’s well being, previous waivers that have approved Medicaid spending on non-health care services have included specific information on the services that will be offered, the populations targeted, and the evidence that 1200 18th Street NW, Suite 200 • Washington, D.C. 20036 • (202) 906-8000 • clasp.org these services will improve health care outcomes. Moreover, all of the services are proposed to be taken away from the core Medicaid entitlement, not capped expenditures. The history of the TANF block grant provides strong evidence that simply stating that any services outside health care being funded with federal dollars will have a "demonstrable connection" to TennCare member health, does not act as a protection. TANF funds may be used for any activity that furthers the four statutory purposes of TANF. States have interpreted this broadly, funding activities from child protective services to college scholarships. In some states, much of this funding has supplanted funding from state general revenues that would otherwise have gone to these purposes, meaning that the total level of investment has not increased. Meanwhile, the share of federal and state TANF funds going to cash assistance has declined to less than a quarter of total spending, even as the overall pool has declined due to inflation. Tennessee provides a striking example of how TANF funds have been diverted away from the core purposes of TANF. In FY 2018, Tennessee reported that only 13.3 percent of total TANF spending was on cash assistance, and just 5.5 percent on work, education and training activities. Program management – essentially administrative costs – consumed 19 percent of TANF spending, and more than 60 percent went to pre-K and Head Start activities.6 The core purpose of Medicaid is to alleviate the burden of accessing essential health services. In the context of a block grant, allowing the state to spend Medicaid dollars on undefined and ambiguous services as long as they have a connection, however tenuous, to health care threatens beneficiaries' access to core health services. Additionally, it perpetuates and increases existing health inequities. Member penalties and lock out periods CLASP has significant concerns about Tennessee’s proposal regarding penalizing member fraud. First, the state provides no information that member fraud is problematic enough that such actions are necessary. Second, the proposed penalties and their implementation raises many concerns and questions. A lock out period of 12 months is both immoral and damaging to beneficiaries’ health. Once suspended from Medicaid coverage, beneficiaries will likely become uninsured. Needed medical services and prescription drugs, including those needed to maintain positive health outcomes, may be deferred or skipped. Because people without health coverage are less likely to have regular care, they are more likely to be hospitalized for avoidable health problems and to experience declines in their overall health.7 Further, during the lock out period, these now-uninsured patients present as uncompensated care to emergency departments, with high levels of need and cost—stretching already overburdened hospitals and clinics. This will only lead to poorer health outcomes and higher uncompensated costs for providers. The impact of even short-term gaps in health insurance coverage has been well documented. In a 2003 analysis, researchers from the Urban Institute found that people who are uninsured for less than 6 months are less likely to have a usual source of care that is not an emergency room, more likely to lack confidence in their ability to get care and more likely to have unmet medical or prescription drug needs.8 A 2006 analysis of Medicaid enrollees in Oregon found that those who lost Medicaid coverage but experienced a coverage gap of fewer than 10 months were less likely to have a primary care visit and more likely to report unmet health care needs and medical debt when compared with those continuously insured.9 1200 18th Street NW, Suite 200 • Washington, D.C. 20036 • (202) 906-8000 • clasp.org The consequences of disruptions in coverage are even more concerning for consumers with high health needs. A 2008 analysis of Medicaid enrollees in California found that interruptions in Medicaid coverage were associated with a higher risk of hospitalization for conditions such as heart failure, diabetes, and chronic obstructive disorders. In addition to the poorer health outcomes for patients, these avoidable hospitalizations are also costly for the state.10 Similarly, a separate 2008 study of Medicaid enrollees with diabetes who experienced disruptions in coverage found that the per member per month cost following reenrollment after a coverage gap rose by an average of $239, and enrollees were more likely to incur inpatient and emergency room expenses following reenrollment compared to the period of time before the enrollee lost coverage.11 Lastly, Tennessee’s proposal that member penalties could be individualized, such as suspending only a portion of a member’s benefits (such as prescription coverage) is extremely administratively complex, and therefore likely expensive. This level of complexity is likely to lead to administrative mistakes and a lack of understanding among members who are penalized. More clarity needed regarding dual eligible population The proposal says that “Expenditures on behalf of individuals who are enrolled in Medicare, including cost sharing and premium assistance (including Medicare Part D “claw back” payments) paid on behalf of individuals who are dually enrolled in Medicare and TennCare” are not included. This language does not make it clear whether all people who are dually eligible for Medicaid and Medicare, including those who are eligible for full Medicaid benefits, are excluded. It could be read to only exclude so-called “partial duals” who are eligible for the Medicare Savings Programs but not for any other Medicaid benefits. Adding to the confusion is the fact that the block grant is calculated using 64,679 “elderly” for the base period enrollment. While the proposal says this number excludes “Medicare members,” we question that it excludes all dually eligible adults age 65 and older. This is because of multiple data sources that show both nationwide and in Tennessee specifically, nearly all seniors enrolled in Medicaid are also enrolled in Medicare. For example, the Census Bureau’s American Community Survey data shows that in 2018, there were 138,000 individuals dually in Medicare and Medicaid in Tennessee who were age 65+. There were also 138,000 Medicaid enrollees age 65+ in Tennessee. This aligns with the Kaiser Family Foundation’s data for 2013: 152,200 Tennessee seniors age 65+ were enrolled in Medicaid 156,000 and 99% of Tennessee Medicaid enrollees age 65+ that year were dual enrolled. In other words, it is impossible that the 64,679 “elderly” that Tennessee is using to calculate its base block grant amount excludes seniors on Medicare. Either this number is a mistake or the state is not intending to exclude all persons dually eligible. Furthermore, the enrollment number the state provides for the “disabled” category does not indicate that it excludes “Medicare members,” which it should if the state is intending to exclude all duals. Should Tennessee choose to move forward with this proposal, we ask that the state to clarify whether it is excluding all dually eligible beneficiaries, regardless of age or type of Medicaid coverage. If this is the case, then the state should acknowledge that it is excluding virtually all of its 65+ Medicaid beneficiaries and not include them in the base calculation. Given these apparent inconsistencies and lack of clarity as to which populations are included in the block grant and which are carved out, we are concerned that the state has not fully thought through the impacts of its proposal. It is critical that the state fully understands the probable impact of capped funding on every single Medicaid population. Conclusion 1200 18th Street NW, Suite 200 • Washington, D.C. 20036 • (202) 906-8000 • clasp.org For all the reasons detailed above, CLASP strongly opposes Amendment 42 to the TennCare waiver. The policies outlined in Amendment 42 would harm Medicaid enrollees in Tennessee by incentivizing federal underspending, increased bureaucracy and red tape, and diverting dollars away from health care. As such, we urge the state to reconsider its approach by withdrawing this waiver amendment and instead focusing on proven ways to increase access to health care and improve health outcomes, such as implementing Medicaid expansion as intended by the Affordable Care Act. Thank you for the opportunity to comment and your review of CLASP’s comments. Please contact Elizabeth Lower-Basch (elowerbasch@clasp.org) with any questions. All sources accessed October 2019. 1 Kaiser Family Foundation, “Health Insurance Coverage of the Total Population,” 2017, https://www.kff.org/other/stateindicator/total-population/?currentTimeframe=0&sortModel= percent7B percent22colId percent22: percent22Location percent22, percent22sort percent22: percent22asc percent22 percent7D; Kaiser Family Foundation, “Health Insurance Coverage of Adults 19-64 Living in Poverty (under 100 percent FPL),” 2017, https://www.kff.org/other/state-indicator/pooradults. 2 Bureau of Labor Statistics, “Lower-wage Workers Pay More Than Higher-wage Workers for Employer-provided Medical Care Benefits,” U.S. Department of Labor, January 2019, https://www.bls.gov/opub/ted/2019/lower-wage-workers-pay-morethan-higher-wage-workers-for-employer-provided-medical-care-benefits.htm. 3 Jane Perkins, “Section 1115 Demonstration Authority: Medicaid Act Provisions That Prohibit a Waiver,” National Health Law Program, 2017, http://www.healthlaw.org/issues/medicaid/waivers/sec-1115-demonstration-authority-medicaidprovisions-that-prohibit-waiver#.WhRlBFWnHIU. 4 Rachel Sachs Nicole Huberfeld, “The Problematic Law and Policy of Medicaid Block Grants,” Health Affairs, July 2019, https://www.healthaffairs.org/do/10.1377/hblog20190722.62519/full/. 5 Tricia Brooks, Edwin Park, and Lauren Roygardner, Medicaid and CHIP Enrollment Decline Suggests the Child Uninsured Rate May Rise Again, Center for Children & Families of the Georgetown University Health Policy Institute, May 2019, https://ccf.georgetown.edu/wp-content/uploads/2019/06/Enrollment-Decline.pdf. 6 Office of Family Assiatnce, TANF and MOE Spending and Transfers by Activity, FY 2018 by State, U.S. Department of Health & Human Services, Spetember 2019, https://www.acf.hhs.gov/sites/default/files/ofa/fy2018_tanf_and_moe_state_piecharts_b508.pdf. 7 Kaiser Family Foundation, “Key Facts About the Uninsured Population” September 2017, http://kff.org/uninsured/factsheet/key-facts-about-the-uninsured-population/. 8 Jennifer Haley and Stephen Zuckerman, “Is Lack of Coverage A Short or Long-Term Condition?,” Kaiser Family Foundation, June 2003, http://kff.org/uninsured/issue-brief/is-lack-of-coverage-a-short-or/. 9 Matthew J. Carlson, Jennifer DeVoe, and Bill J. Wright, Short-Term Impacts of Coverage Loss in a Medicaid Population: Early Results From a Prospective Cohort Study of the Oregon Health Plan, Annals of Family Medicine, 2006, http://www.annfammed.org/content/4/5/391.short. 10 Andrew Bindman, Amitabha Chattopadhyay, and G. M. Auerback, “Interruptions in Medicaid Coverage and Risk for Hospitalization for Ambulatory Care-sensitive Conditions,” Annals of Internal Medicine, 2008, https://www.ncbi.nlm.nih.gov/pubmed/19075204?dopt=Abstract. 11 Allyson G. Hall, Jeffrey S. Harman and Jianyi Zhang, “Lapses in Medicaid Coverage: Impact on Cost and Utilization Among Individuals With Diabetes Enrolled in Medicaid,” Medical Care, Vol. 46, No. 12, December 2008, https://www.ncbi.nlm.nih.gov/pubmed/19300311?dopt=Abstract. 1200 18th Street NW, Suite 200 • Washington, D.C. 20036 • (202) 906-8000 • clasp.org Jonathan Reeve From: Sent: To: Subject: Attachments: Consumers for Quality Care Friday, October 18, 2019 11:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare II Demonstration Amendment 42 “Block Grant Waiver Comment TN Comment Letter CQC 10.18.19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Attached, please see a comment letter re: TennCare II Demonstration Amendment 42 “Block Grant Waiver signed by the following organizations:         Consumers for Quality Care  Allergy & Asthma Network  Consumer Action  First Focus on Children  MANA, A National Latina Organization  Patient Power   Thank you for the opportunity to comment on this proposal.    1 October 18, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: We appreciate the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4). The purpose of the Medicaid program is to provide health care coverage for low-income individuals and families. As health care advocates and consumer organizations, we work to ensure that consumers are at the front and center of the health care debate, and we are committed to ensuring that TennCare provides quality and affordable health care coverage. Unfortunately, this waiver proposal to convert the funding structure of the TennCare program to a block grant will jeopardize beneficiaries’ access to care. We oppose Tennessee’s proposal and offers the following comments. Block Grant Structure We oppose Tennessee’s proposal to change the financing structure for its Medicaid program to a block grant. We fear that the state will cut coverage for certain treatments completely or impose additional barriers to important services, making it more difficult for patients to access the care that they need. Additionally, Tennessee may choose to cut payments to providers to help keep spending under the new block grant. As the gap between the block grant and actual costs of care increases over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients will only increase. These cuts are unacceptable. Tennessee’s proposal would include vulnerable eligibility groups such as children and people with disabilities in the block grant. We have serious concerns about how this will impact their care. Additionally, under this proposal, current and future administrations would not need to get approval to make changes to benefits and services, putting these patients’ care at grave risk. Changing TennCare to a block grant through the 1115 waiver process is illegal. The Secretary of Health and Human Services is not permitted to waive Sections 1903 and 1905, where the financing structure of the Medicaid program is located, through these types of waivers, as multiple experts have noted.1,2 Such a change would require congressional authority, yet Congress has repeatedly declined to pass legislation on this issue, most recently during the debate over repealing and replacing the Affordable Care Act in 2017. Prescription Drug Access We oppose the proposal to create a closed formulary with as few as one drug per class and exclude prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated approval process. Limiting access to medications will be detrimental to Americans. Prescription drugs have different indications, different mechanisms of action, and different side effects, depending on the person’s diagnosis and comorbidities. Restricting TennCare’s drug benefits to a closed formulary would limit the ability of providers to make the best medical decisions for the care of their patients, effectively taking the clinical care decisions away from the doctor and patient and giving them to the state. The waiver proposal does not include an appeals process for patients to access prescription drugs that are no longer covered. TennCare patients include very low-income pregnant women, the elderly, children and the blind and disabled. These individuals rely on Medicaid to provide treatment and may need access to a medication no longer covered under the new restrictions. Without an appeals process to access denied medications, these patients could experience worse health outcomes and even death. State Flexibilities We oppose a number of proposals in the waiver application considered under the broad moniker of “state flexibilities.” Tennessee is asking to be exempt from federal standards and requirements for its managed care program, including the Managed Care Rule. This important safeguard ensures Medicaid Managed Care Organizations (MCOs) have to meet certain requirements related to patient care. For example, the managed care rule sets standards related to adequate networks, so patients can actually see the appropriate providers and receive the care they need. The managed care rule requires MCOs to comply with standards of time and distance to measure this network adequacy, helping patients access both primary care providers and specialists they need. Tennessee is asking to change the “amount, duration, and scope” of benefits, which could allow the state to put caps on services or only cover critical services for certain individuals. The Medicaid population, by definition is a vulnerable population, allowing Tennessee to change the “amount, duration, and scope” of benefits could negatively impact patient care and outcomes. One example might be limiting the number of days a patient could stay in the hospital. Finally, the state would no longer need to get approval to make changes to benefits and services in the future and would like to make this demonstration permanent, removing important opportunities for the public to provide feedback on the how the program is working for key stakeholders before any policies are implemented or continued. It is especially important that beneficiaries impacted by the demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint venture between Tennessee and CMS. Both entities, as well as the people it serves, should have a voice in how the program is administered. The core objective of the Medicaid program is to furnish health care to low-income and needy populations. This waiver does not further that goal and we oppose the proposal. Thank you for the opportunity to submit comments. Sincerely, Consumers for Quality Care Allergy & Asthma Network Consumer Action First Focus on Children MANA, A National Latina Organization Patient Power 1 Joan Alker. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown University Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/ pending-cms-guidance-on-medicaid-block-grants-executive-overreach-strikes-again/. 2 https://theincidentaleconomist.com/wordpress/tennessee-wants-to-block-grant-medicaid-is-that-legal/ Jonathan Reeve From: Sent: To: Subject: Attachments: Evans-Dill, Cyndi Friday, October 18, 2019 12:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments THCA Comments on TennCare Amendment #42 - Block Grant Waiver 4821-9363-3193 2 (002).pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please see attached.    Cyndi A Evans-Dill Legal Assistant to Christopher C. Puri e: cevans-dill@bradley.com w: bradley.com d: 615.252.3533 Bradley Arant Boult Cummings LLP Roundabout Plaza, 1600 Division Street, Suite 700 Nashville, TN 37203 LinkedIn Facebook Twitter Instagram Blogs     Confidentiality Notice: This e-mail is from a law firm and may be protected by the attorney-client or work product privileges. If you have received this message in error, please notify the sender by replying to this e-mail and then delete it from your computer.  1 Comments of the Tennessee Health Care Association/ Tennessee Center for Assisted Living on Notice of Change in TennCare II Demonstration Amendment 42 (“TennCare Block Grant Proposal”) via email to: public.notice.tenncare@tn.gov Submitted: October 18, 2019 The Tennessee Health Care Association/Tennessee Center for Assisted Living (THCA/TNCAL) appreciates the opportunity to comment on TennCare II Demonstration Amendment 42. The Bureau of TennCare posted the proposal on its website and solicited public comment. This amendment, which will be known as “Amendment 42,” will be filed with the Centers for Medicare & Medicaid Services (CMS). Through Amendment 42, the State is proposing to convert the bulk of TennCare’s federal funding to a block grant and receive approval from CMS to do so. THCA/TNCAL (“We”) is a statewide association representing nursing facilities and assisted living communities. We appreciate the opportunity to offer public comment on this extremely important proposal that would substantially change the structure of the TennCare program. THCA/TNCAL’s comments are provided in each section below. A. Introductory and General Comments THCA/TNCAL supports the state of Tennessee and the TennCare Bureau in its efforts to pursue alternative funding sources from the federal government for purposes of assisting the state Medicaid program, so long as any proposed and/or finally adopted program provides sustainability for the state's most vulnerable elderly population and their option to have nursing facility services when needed. In order to accomplish this important goal, THCA/TNCAL recommends certain provisions be placed into any waiver application to CMS. Further, it is THCA’s expectation that there will be a need to promulgate new rules and statutes to operationalize the block grant. We look forward to providing additional input at the appropriate time. We appreciate TennCare incorporating so many of the features that are so important to THCA/TNCAL’s members. For example, THCA/TNCAL supports the adoption within the proposed Amendment 42 of the following elements reducing Tennessee’s risk, including: Comments of THCA/TNCAL – TennCare Amendment #42 – Block Grant October 18, 2019 Page 2 • • • Per capita adjustments to the block grant funding amounts to reflect growth in TennCare enrollment that may occur in future years that was not present in the base period enrollment on which the block grant is calculated. This per capita adjustment preserves the ability for increased enrollment in the aged, blind and disabled population for those who meet the nursing facility medical and financial eligibility criteria established by the state. A growth rate for inflation factor so the amount of the block grant will be inflated annually to account for year-over-year price inflation. The inclusion of a request to CMS to modify the federal Medicare wage index adjustment that unfairly impacts long-term services and supports (LTSS) providers through the loss of significant Medicare revenues every year. We suggest the proposal adopt a wage index adjustment that will ultimately implement a floor of eighty-five percent (85%) for the metropolitan statistics areas (MSA) and rural regions of Tennessee. THCA also supports TennCare’s efforts to ensure nursing facility care is a mandatory covered service under the Tennessee Medicaid program and the proposed Amendment 42. As stated in the notice regarding Amendment 42, TennCare states: “Amendment 42 does not rely on reductions to eligibility or benefits in order to achieve savings under the block grant” We strongly support TennCare’s decision to maintain nursing facility services as a mandatory covered service under the TennCare program and maintain current eligibility standards, as we interpret the proposal. We further address the proposal requests regarding “amount, scope, and duration” of services later in our comments. THCA/TNCAL’s main position is that any proposed or finally adopted amendment to TennCare do two things: • • B. Ensure TennCare beneficiaries have the same access to nursing facility services, under the same terms and conditions as are currently in place, after the implementation of any waiver modifications or block grant. Ensure TennCare nursing facilities continue to be reimbursed under the same terms and conditions as are currently in place after the implementation of any waiver modifications or block grant. Treatment of Dually Eligible Individuals THCA/TNCAL requests TennCare provide further clarification regarding the treatment of individuals who are eligible for both Medicare and Medicaid (i.e., “dual eligibles”) under the Comments of THCA/TNCAL – TennCare Amendment #42 – Block Grant October 18, 2019 Page 3 block grant proposal and Amendment 42. On pages 10-11 of the Amendment 42 Draft document (“Waiver Draft”), the Division of TennCare suggests dual eligible individuals will be an excluded category of person, stating: Therefore, the state proposes to exclude certain expenditures from the block grant financing model described above. Specifically, the state proposes to exclude: …4. Expenditures on behalf of individuals who are enrolled in Medicare, including cost sharing and premium assistance (including Medicare Part D “claw back” payments) paid on behalf of individuals who are dually enrolled in Medicare and TennCare; While this statement makes clear that dual eligible will be excluded from the calculations of payments related to the block grant, the Waiver Draft does not, in any way, appear to exclude dual eligible populations from any other programmatic changes to the TennCare program that appear later in the Waiver Draft. For example, Section IV (State Flexibilities) of the Waiver Draft suggests an array of changes that TennCare would have the authority to adopt (i.e., closed formularies, changes in benefit amount/duration/scope, innovative delivery programs, differential benefits package, etc.). It is not clear whether the dual eligible population within TennCare, and more specifically the CHOICES eligible populations, would be exposed to these changes in a proposed new TennCare program under Amendment 42. We request TennCare clarify whether dual eligible individuals will be included or excluded from the proposed programmatic changes within Amendment 42. C. Adoption of a Mandatory Closed Drug Formulary On page 14 of the Waiver Draft, the Division of TennCare requests changes relative to drug coverage policies, stating: The state proposes that it have the flexibility under this demonstration to adopt a commercial-style closed formulary with at least one drug available per therapeutic class…Adopting these practices would allow TennCare to implement the same basic formulary management strategies available to virtually all other payers and avoid exorbitant spending on high-cost drugs that are not medically necessary, which do not provide additional clinical benefit, and/or which actually pose health risks for members when prescribed without sufficient medical evidence, while continuing to ensure that members have access to at least one effective, medically necessary medication in every therapeutic class.; THCA/TNCAL is supportive of the state’s overall efforts to effectively manage prescription drug spending within the TennCare program. However, there are two situations where a closed formulary could inadvertently and negatively impact the nursing facility population. DRAFT – FOR REVIEW ONLY ACP/AWP Comments of THCA/TNCAL – TennCare Amendment #42 – Block Grant October 18, 2019 Page 4 Nursing facility providers are subject to regulations that significantly differ from the community setting. A nursing facility must provide all the services necessary for the care of an individual resident, and must follow and execute all physician’s orders. Physician’s orders nearly always include medications for the resident. Unlike a community setting, or even in a hospital setting, a nursing facility has little to no control over a physician’s prescribing choices. Therefore, if a closed limited formulary is imposed on the CHOICES population, facilities could often be forced to provide a non-formulary drug without reimbursement. The instances of this could be limited because most residents receive medications through the Medicare Part D program. However, THCA estimates approximately five percent (5%) of the nursing facility population are non-dual eligible TennCare beneficiaries. Many of these individuals have profound life-limiting conditions from traumatic brain injuries or, in some cases, developmental disabilities. THCA/TNCAL requests that any closed formulary not apply to the nursing facility population for the following reasons: First, the facility has no ability to influence the choice of medication by the attending physician, and must deliver the medication as ordered. Facilities would be forced to absorb the costs of a non-covered drug. Second, efforts by the facility to adopt formulary changes would likely increase burdens on attending physicians. It is already difficult to attract qualified physicians to practice in long-term care. Imposing a closed formulary could exacerbate the burdens on long-term care facilities and their attending physicians. Doing so would be contrary to improving nursing facility patient care. D. Amount, Duration and Scope of Benefits / Waiver of Comparability As noted above, elsewhere in the Waiver Draft, TennCare explicitly states Amendment 42 does not rely on reductions to eligibility or benefits in order to achieve savings under the block grant. TennCare states on page 3, “The state’s proposal does not rely on reductions to eligibility or benefits in order to achieve savings, and indeed, does not request any significant changes in those areas.” (emphasis added). However, in the discussion of state flexibility, the state repeatedly requests relief from current CMS restrictions on the ability to modify benefits. For example: The state proposes that it have the flexibility under this demonstration to vary benefits packages for different members based on medical factors or other considerations (p.20) To the extent that the state, under this demonstration, will be operating its Medicaid program under a block grant, the state should have autonomy to Comments of THCA/TNCAL – TennCare Amendment #42 – Block Grant October 18, 2019 Page 5 make adjustments to its package of covered benefits as it determines necessary to best promote the health of its members. (p.20) On page 14 of the Waiver Draft, the Division of TennCare suggests differential benefits would be allowed and/or requested within a proposed waiver, stating: For example, the comparability requirement prevents a state that wishes to explore emerging therapies and treatment modalities from implementing limited pilot programs designed to assess their clinical efficacy and potential cost effectiveness, or to use a small-scale pilot process to inform the statewide rollout of a new benefit or service… The state proposes that it have the flexibility under this demonstration to vary benefits packages for different members based on medical factors or other considerations. TennCare already has significant experience with waivers of comparability, particularly in the TennCare demonstration’s managed long term services and supports programs, where the state has demonstrated the potential for achieving both improved outcomes and lower costs by targeting benefits to members based on their actual level of need. As TennCare is aware, the implementation of CHOICES and the achievement of a quality and acuity-based nursing facility reimbursement system have been significant modifications in the Medicaid program for nursing facility providers. In 2012, TennCare adopted a dramatic change from existing Medicaid LTSS functional eligibility criteria. The change significantly restricted eligibility for CHOICES Group 1 nursing facility services by moving to an acuitybased scoring matrix, where a pre-determined “score” in activities of daily living (ADLs) was now needed to meet the functional eligibility criteria for CHOICES to receive nursing home care. TennCare along with THCA and its members worked very cooperatively and very diligently on the development of the new reimbursement system. We appreciate the efforts TennCare has made to develop a system that provides the right “aligned incentives” in both quality and appropriate reimbursement for facilities. To that end and, as noted above, THCA would oppose any efforts by TennCare to alter the access to nursing facility services, for example, through a more restrictive eligibility criteria or a modified benefit package through a waiver of comparability on those benefits. Assuming then, the intention of the waiver makes no significant modifications to the nursing facility benefits or reimbursement, we would seek TennCare’s support for the codification of important components of nursing facility services and reimbursement within state statute. DRAFT – FOR REVIEW ONLY ACP/AWP Comments of THCA/TNCAL – TennCare Amendment #42 – Block Grant October 18, 2019 Page 6 E. Non-Compliance with 42 C.F.R. §438 – Medicaid Managed Care Requirements As part of Amendment 42, TennCare seeks a complete exemption from the provisions of 42 C.F.R. Part 438. The provisions in this section of the federal regulations set forth comprehensive requirements for Medicaid managed care programs, CMS’ standards for approval of those programs and oversight obligations that states have over the managed care organizations delivering those Medicaid services. While certain provisions within 42 C.F.R. part 438 may be “overly prescriptive and unnecessary federal regulations,” there are also very important sections within those regulations that provide protections for both beneficiaries and providers. For example, the Medicaid managed care provisions provide for: • A required medical loss ratio of at least eighty-five percent (85%) to ensure Medicaid capitation payments are spent primarily on the provision of care. (42 C.F.R. §483.8) • The requirement that each MCO providing LTSS have a member advisory committee. (42 C.F.R. §438.110) • • • • Enrollee control in their choice of network providers (42 C.F.R. §483.3(l)). Guardrails to prevent discrimination against certain providers (42 C.F.R. §438.12) Comprehensive enrollee rights and protections (42 C.F.R. §438 subpart C) Comprehensive beneficiary appeals and grievance provisions (42 C.F.R. §438 subpart F) THCA opposes the complete waiver of the Medicaid managed care regulations absent the express commitment by the state to adopt similar, necessary provisions within the Tennessee Code. The Waiver Draft provides no detail or discussion about how TennCare would ensure beneficiaries would be protected from abuses and/or inappropriate behaviors on the part of MCOs. The Waiver Draft also provides no detail or discussion about what guardrails TennCare would put in state law to give providers necessary transparency and input into how their relationships with TennCare and its MCOs are organized. THCA acknowledges certain provisions contained within 42 C.F.R. §438 may also be included by TennCare within its contractor risk agreements (CRA). However, a complete waiver of 42 C.F.R. §438 without some replacement within state statutes would provide inadequate protection for both beneficiaries and providers alike. There is no established process providing for transparency in the development of the CRA and any changes to it. Unlike notice and comment rulemaking under the Tennessee Administrative Procedures Act, there is no established process for the public to learn of and provide comment or objection to provisions on CRA requirements or the lack of certain provisions in the CRA. Lastly, since the CRA is merely a contract between TennCare and its MCOs, all of the CRA provisions are Comments of THCA/TNCAL – TennCare Amendment #42 – Block Grant October 18, 2019 Page 7 ultimately, solely the result of TennCare’s negotiations with those MCOs. For example, if the requirements relative to grievance and appeals at 42 C.F.R. §483.12 are waived, with no corresponding state legislative requirements, beneficiaries would be left solely with whatever TennCare could negotiate with the MCOs regarding appeals. Such a scenario would provide significant flexibility to TennCare, but may result in a very high cost to providers and beneficiaries with respect to transparency and opportunities for input. Again, it is THCA’s position that the waiver of all federal provisions should be accompanied by a commitment by TennCare to enact the substance of certain of those protections within Tennessee law. F. TennCare Waiver Should Modify Other Medicaid Provisions: In the draft of Amendment 42, TennCare proposes to use the flexibility granted by Section 1115 and 1115A to promote a comprehensive redesign of the Medicaid program with respect to financing and, in some areas, how benefits are delivered to eligible individuals. Because TennCare proposes such an extensive redesign, it should also propose certain additional provisions that ameliorate longstanding issues providers, and especially longterm care providers, have with the existing administrative features of the TennCare program. As has been outlined by THCA in numerous meetings with TennCare, obtaining prompt eligibility approval for CHOICES beneficiaries continues to be a problem. In its waiver proposal, TennCare should propose to add a mechanism for initial presumptive eligibility for LTSS beneficiaries. Sufficient measures could be included to recoup funds paid for individuals who ultimately do not become eligible. However, since the vast majority of individuals do become eligible for LTSS, requesting flexibility for presumptive eligibility would streamline and improve the eligibility process for beneficiaries and providers. Similarly, in requesting relief from certain onerous provisions of the managed care regulations at 42 C.F.R. Part 438, TennCare could also request authority in its waiver changes that make the provider change of ownership process more streamlined and efficient, and to simplify the increasingly complexities of credentialing of providers by managed care organizations. Under current provisions, too often nursing facilities are changing ownership, but then waiting months for the initiation of Medicaid payments from managed care entities because of unnecessary and unduly burdensome administrative provisions from TennCare and the MCOs. THCA recommends TennCare improve its waiver proposal by including requests for waiver authority to make revisions to add presumptive eligibility and to have authority to redesign the Medicaid provider change of ownership and credentialing process. DRAFT – FOR REVIEW ONLY ACP/AWP Comments of THCA/TNCAL – TennCare Amendment #42 – Block Grant October 18, 2019 Page 8 G. Additional Questions: In addition to the specific provisions and recommendations discussed, THCA/TNCAL also has the following additional questions: 1. Funding for Excluded Populations: How will funding for populations not included in the block grant be preserved, especially during economic downturns? Could block grant savings be used to support programs for excluded populations? 2. Future Inclusion of Excluded Populations: If the block grant is successful, would the state plan to move currently excluded populations into the program in the future? 3. Transparency and Stakeholder Input on Modifications: Given the flexibility and fewer approvals the state is requesting from the federal government, how does the state plan to solicit stakeholder feedback and what processes would there be to ensure transparency related to any state level program changes? 4. Investment in Innovation for LTSS: The proposal indicates the state will be making investments to help foster new, innovative care delivery approaches. For example, on page 2 of the Waiver Draft TennCare states, “TennCare now finds itself in a position of needing to identify or develop new, innovative care delivery approaches that may require short-term investments of new dollars, but which will—over time—reduce (or at least contain the growth of) the cost of care.” What types of investments are the state considering for long-term services and supports? 5. Impact on Medicaid Funding Mechanisms: How does the state anticipate existing Medicaid financing mechanisms (e.g., provider assessments) will be impacted by the block grant proposal? 6. Additional Public Input: Should TennCare and CMS come to an agreement, will there be additional opportunities for public input prior to the block grant proposal being submitted to the state legislature? Conclusion We thank you for the opportunity to comment regarding TennCare Amendment 42. We understand this draft is the initial stage in the development of a block grant process with numerous steps to follow that may result in substantial changes to the current proposal. Those changes may significantly alter our perspective with respect to our comments. Jonathan Reeve From: Sent: To: Cc: Subject: Ryan, Lauren Friday, October 18, 2019 4:15 PM PUBLICE NOTICE TENNCARE Kellermann, Adam [EXTERNAL] CFF Comments - Tennessee TennCare II Demonstration Amendment 42 “Block Grant Waiver” CFF State Comments_TN 1115 Waiver_2019.10_Final.pdf Attachments:   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To whom it may concern:     Thank you for the opportunity to comment on Tennessee’s Medicaid Waiver Amendment 42. On behalf people with  cystic fibrosis (CF) in Tennessee, we write to express our serious concerns regarding several provisions in the proposed  waiver application. Please see attached for our full comments.     Best,     Lauren Ryan Sr. Specialist, State Policy O: 301.841.2632 E: lryan@cff.org   4550 Montgomery Ave., Suite 1100N, Bethesda, MD 20814                    DISCLAIMER: This email may contain confidential information, which may be protected by applicable privileges and may constitute  non‐public information. It is intended to be conveyed only to the designated recipient(s) of the message. If you are not an intended  recipient of this message, please notify the sender. Unauthorized use, dissemination, distribution, or reproduction of this message is  strictly prohibited and may be unlawful.     1 October 18, 2019 Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 RE: Tennessee TennCare II Demonstration Amendment 42 “Block Grant Waiver” Dear Director Roberts: Thank you for the opportunity to comment on Tennessee’s Medicaid Waiver Amendment 42. On behalf of more than 700 people with cystic fibrosis (CF) in Tennessee, we write to express our serious concerns regarding several provisions in the proposed waiver application—including the request to change TennCare’s funding structure, adopt a closed formulary, reduce federal oversight of TennCare, and divert funds to other initiatives. We oppose the proposal to implement block grant funding and ask the state to not submit the proposed waiver provisions not required by state law. Cystic fibrosis (CF) is a life-threatening genetic disease that affects 30,000 children and adults in the United States. CF causes the body to produce thick, sticky mucus that clogs the lungs and digestive system, which can lead to life-threatening infections. As a complex, multi-system condition, CF requires targeted, specialized treatment and medications. Medicaid is a crucial source of coverage for patients with serious and chronic health care needs, including those with CF. Decreased access that could result from funding reductions, benefit restrictions, or other program changes would be devastating to those who rely on high-quality CF care to maintain their health and well-being. In the TennCare II Demonstration Amendment 42 application, Tennessee proposes drastic changes to the program’s financing, benefit structure, and program safeguards. Given how these changes could impact those with CF in Medicaid, we have serious concerns with this waiver application. Block Grant Funding Model We have serious concerns that the block grant funding proposal creates a framework for Tennessee to restrict TennCare funding—both because this model relies on a rigid funding structure that is not responsive to changes in program costs and because the waiver contains incentives for Tennessee to reduce program spending that may have negative consequences for the CF population. While the proposal includes an adjustment for unexpected enrollment growth, it does not account for other changes in program needs. Tennessee would remain responsible for other unexpected increases in per-person TennCare costs, such as increased costs due to public health crises or innovations in medical treatment. In these situations, the state may not be able to provide the additional funds needed to cover cost increases and may look to cut benefits, eligibility, and/or provider rates. Such threats are particularly acute given the additional flexibilities the state is requesting around benefits and managed care plan oversight, as discussed below. For patients with serious chronic conditions like CF, such cuts could mean Medicaid no longer provides access to their care provider or covers the complex, specialized care they need. Lack of proper care could lead to an CYSTIC FIBROSIS FOUNDATION NATIONAL OFFICE 4550 MONTGOMERY AVENUE SUITE 1100N BETHESDA, MD 20814 TEL: 800.FIGHT.CF FAX: 301.951.6378 WEB: WWW.CFF.ORG increase in hospitalizations, decrease in lung function, or decrease in Body Mass Index, all dire consequences for someone with cystic fibrosis. The waiver also contains an incentive for Tennessee to find ways to reduce program spending. Tennessee already has the fifth lowest per-person Medicaid spending in the country. Under the current financing system, Tennessee loses federal funding when it reduces Medicaid spending. This proposal would effectively reverse the incentives for the state by allowing Tennessee to recoup 50 percent of unspent federal funds for every dollar cut from TennCare—creating a financial reward for cutting Medicaid spending. This “shared savings” model encourages the state to maximize savings by cutting benefits or adding program barriers to enrollment. Beyond our above concerns, we also believe the request for block grant funding violates federal statute. Under Section 1115 of the Social Security Act, the Secretary of Health and Human Services has the authority to waive compliance with multiple sections of the Act when they are “likely to assist in promoting the objectives” of the Medicaid program.1 However, the Medicaid payment model and match rates are outlined in Sections 1903 and 1905, sections notably absent from the list of waivable provisions under Section 1115.2 As the Centers for Medicare and Medicaid Services (CMS) itself recently acknowledged to North Carolina, we do not believe the state’s proposed funding structure is approvable under federal law.3,4 “Commercial-style” Closed Formulary Tennessee is also requesting the flexibility “to adopt a commercial-style closed formulary with at least one drug available per therapeutic class.” CFF appreciates the reality that growth in drug costs contributes to the increasing strain on state budgets. However, we are concerned that the state’s proposal to adopt a closed formulary based on cost-effectiveness reviews is underdeveloped, inappropriate based on the availability of existing data, and could create barriers to life-saving treatments. The state’s plan to implement a closed formulary and base coverage decisions on cost-effectiveness reviews is woefully underdeveloped. Tennessee provides no details as to how it would determine when “market prices are consistent with prudent fiscal administration” nor does the state outline any process for how it would conduct cost-effectiveness reviews or what data would be considered during such discussions. If Tennessee is serious about such an endeavor—in which patients’ access to clinically beneficial, sometimes life-saving, therapies is at stake—the state must provide a detailed proposal about how such a process would work. We also caution the state that cost-effectiveness assessments are limited by the availability and quality of data available at the time the review is conducted. This can significantly impact the outcome of such assessments, especially when cost-effectiveness is evaluated when a drug enters the market or is new-to-market. In such 1 Social Security Act § 1115(a) Hannah Katch, Judith Solomon, and Aviva Aron-Dine, “Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries” Center on Budget and Policy Priorities, September 25, 2019, https://www.cbpp.org/research/health/tennessee-block-grant-proposal-threatens-care-for-medicaid-beneficiaries 3 Social Security Act § 1115(a) 4 Centers for Medicare & Medicaid Services, North Carolina Medicaid Reform Demonstration Approval, October 19, 2018, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nc/MedicaidReform/nc-medicaid-reform-demo-demo-appvl-20181019.pdf. 2 CYSTIC FIBROSIS FOUNDATION NATIONAL OFFICE 4550 MONTGOMERY AVENUE SUITE 1100N BETHESDA, MD 20814 TEL: 800.FIGHT.CF FAX: 301.951.6378 WEB: WWW.CFF.ORG circumstances, long-term outcomes and patient experience data do not yet exist. Even when clinical evidence is available, current assessments incorporate very limited patient-relevant information such as real-world evidence, patient experience, and patient survey data, if any. Thus, these assessments often undervalue longterm benefits and real-world outcomes of patients and should not be the sole basis for coverage decisions. Additionally, the administration has made its position on this issue clear: in a 2018 notice, the Department of Health and Human Services stated that any drug manufactured by a company with a Medicaid National Drug Rebate agreement “is covered by the Medicaid Drug Rebate Program (MDRP) and is to be covered by state Medicaid programs.”5 CMS also rejected a comparable proposal submitted by Massachusetts in 2017, citing a similar rationale.6 Thus, Tennessee’s proposal to restrict drug coverage as proposed in this waiver is not a viable option under federal statute.7 State Flexibility and Waived Oversight Tennessee is also requesting increased program flexibility that could result in reduced benefits and protections for people who rely on TennCare. Tennessee is seeking new authority to change its TennCare benefits package, including through the addition or elimination of optional benefits and changes in the amount, duration, and scope of covered benefits without federal approval. This flexibility would permit the state to cap services, such as hospitalizations, or limit critical services for only certain individuals. While the state presents this as a way to increase services to some beneficiaries, the flexibility requested by the state could result in abrupt cuts to services for beneficiaries, including people with severe and chronic conditions like CF, without any federal oversight to ensure the program is meeting its core objectives. We are also concerned with the state’s proposal to waive federal managed care requirements which set standards for provider network adequacy, access to care, actuarially sound rates, appeals processes, and quality improvement. All TennCare beneficiaries, including people with CF, are enrolled in managed care. These safeguards protect their access to services and their ability to appeal treatment denials. For someone with cystic fibrosis who requires access to specialty care centers and complex therapies, these protections are vital. Waiving federal regulations would eliminate core safeguards that ensure people with CF who rely on TennCare are provided with a minimum standard of coverage. Diverting funds to non-TennCare Initiatives This waiver application also gives Tennessee the authority to divert Medicaid dollars to fund other health care initiatives that may not specifically assist the TennCare population. While we appreciate and support the state’s desire to invest in nutritional assistance, rural healthcare transformation, and other initiatives that can improve health outcomes across the state, we are concerned that funding intended for low-income TennCare 5 Centers for Medicare & Medicaid Services, Medicaid Drug Rebate Program Notice Release No. 185, June 27, 2018, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/downloads/rx-releases/statereleases/state-rel-185.pdf 6 Centers for Medicare & Medicaid Services, MassHealth Demonstration Amendment Approval, June 27, 2018, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/MassHealth/mamasshealth-demo-amndmnt-appvl-jun-2018.pdf. 7 Social Security Act § 1927(d), 42 U.S.C. § 1396r-8. CYSTIC FIBROSIS FOUNDATION NATIONAL OFFICE 4550 MONTGOMERY AVENUE SUITE 1100N BETHESDA, MD 20814 TEL: 800.FIGHT.CF FAX: 301.951.6378 WEB: WWW.CFF.ORG beneficiaries would shift outside the program – resulting in benefit reductions. We therefore urge you to ensure that federal Medicaid dollars are used specifically to support TennCare beneficiaries. In conclusion, we oppose the above-mentioned policies and ask you to withdraw all proposals in this waiver not required by state law. The Cystic Fibrosis Foundation appreciates your attention to these important issues. As the health care landscape continues to evolve, we look forward to working with the state of Tennessee to improve the lives of all people with cystic fibrosis. Please consider us a resource moving forward. Sincerely, Mary B. Dwight Senior VP of Policy & Advocacy Cystic Fibrosis Foundation Lisa Feng, DrPH Senior Director of Policy & Advocacy Cystic Fibrosis Foundation Rebekah Flowers Brown, MD Director, Cystic Fibrosis Care Center Vanderbilt Children's Hospital Joel Ledbetter, MD Director, Cystic Fibrosis Care Center T.C. Thompson Children's Hospital Diana R Quintero, MD Director, Cystic Fibrosis Care Center East Tennessee Children's Hospital Saumini Srinivasan, MD, MS Director, Cystic Fibrosis Care Center University of Tennessee CF Care and Research Center James J. Tolle, MD Director, Cystic Fibrosis Care Center Vanderbilt University Medical Center CYSTIC FIBROSIS FOUNDATION NATIONAL OFFICE 4550 MONTGOMERY AVENUE SUITE 1100N BETHESDA, MD 20814 TEL: 800.FIGHT.CF FAX: 301.951.6378 WEB: WWW.CFF.ORG Jonathan Reeve From: Sent: To: Subject: Danielle Del Carlo Friday, October 18, 2019 2:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] NORD Comments Re: TennCare II Demonstration Amendment 42 (Project No. 11W-00151/4) TN Final TennCare II Demonstration Amendment 43 block grant waiver Comments 10.18.19.docx Attachments:   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts,    Please see attached comments regarding TennCare II Demonstration Amendment 42 (Project No. 11-W00151/4).     Thank you for the opportunity to comment on this legislation. For further questions, please do not hesitate to contact me at ddelcarlo@rarediseases.org.       Best,    Danielle      ‐‐     Danielle Del Carlo  Director of State Policy National Organization for Rare Disorders a: 1779 Massachusetts Ave., NW, Suite 500, Washington, DC 20036 w: rarediseases.org e: ddelcarlo@rarediseases.org                      Confidentiality Note: This email and any attachments may contain confidential and privileged material for the sole use of the intended recipient. Any review, use,  distribution or disclosure by others is strictly prohibited. If you are not the intended recipient (or authorized to receive for the recipient), please delete the email,  along with any attachments, without copying or disclosing it and notify the sender by reply email immediately.   1   October 18, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Transmitted via email to public.notice.tenncare@tn.gov Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: On behalf of the 1-in-10 individuals in Tennessee with one of the approximately 7,000 known rare diseases, the National Organization for Rare Disorders (NORD) thanks you for the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4). NORD is a unique federation of voluntary health organizations dedicated to helping people with rare "orphan" diseases and assisting the organizations that serve them. We are committed to the identification, treatment, and cure of rare disorders through programs of education, advocacy, research, and patient services. The purpose of the Medicaid program is to provide healthcare coverage for low-income individuals and families. NORD is committed to ensuring that TennCare provides quality and affordable healthcare coverage. Unfortunately, this waiver proposal to convert the funding structure of the TennCare program to a block grant will jeopardize beneficiaries’ access to care. NORD opposes Tennessee’s proposal and offers the following comments. Block Grant Structure NORD opposes Tennessee’s proposal to change the financing structure for its Medicaid program to a block grant. NORD fears that the state will cut coverage for certain treatments completely or impose additional barriers to important services, making it more difficult for patients to access the care that they need. Additionally, Tennessee may choose to cut payments to providers to help keep spending under the new block grant. As the gap between the block grant and actual costs of care increases over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients will only increase. These cuts are unacceptable. This structure will not protect either the state or beneficiaries from financial risk. The per capita adjustments to the block grant will not be sufficient if an unexpected event, such as a public health crisis, increases per person healthcare costs. For example, there are many ground-breaking treatments in development for patients with serious and chronic illnesses. If an expensive but highly effective     treatment became available, Tennessee’s spending could rise, putting the state’s budget at risk and creating an incentive for the state to impose additional barriers for that treatment. Tennessee’s proposal would include vulnerable eligibility groups such as children and people with disabilities in the block grant. We have serious concerns about how this will impact their care. Additionally, under this proposal, current and future administrations would not need to get approval to make changes to benefits and services, putting these patients’ care at grave risk. Changing TennCare to a block grant through the 1115 waiver process is illegal. The Secretary of Health and Human Services is not permitted to waive Sections 1903 and 1905, where the financing structure of the Medicaid program is located, through these types of waivers, as multiple experts have noted.i,ii Such a change would require congressional authority, yet Congress has repeatedly declined to pass legislation on this issue, most recently during the debate over repealing and replacing the Affordable Care Act in 2017. Prescription Drug Access NORD opposes the proposal to create a closed formulary with as few as one drug per class and exclude prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated approval process. Limiting access to medications will be detrimental. Prescription drugs have different indications, different mechanisms of action, and different side effects, depending on the person’s diagnosis and comorbidities. Restricting TennCare’s drug benefits to a closed formulary would limit the ability of providers to make the best medical decisions for the care of their patients, effectively taking the clinical care decisions away from the doctor and patient and giving them to the state. Allowing TennCare to exclude prescription drugs approved through FDA’s accelerated processes will harm patients by restricting access to novel and lifesaving therapies. The waiver proposal does not include an appeals process for patients to access prescription drugs that are no longer covered. TennCare patients include very low-income pregnant women, the elderly, children and the blind and disabled. These individuals rely on Medicaid to provide treatment and may need access to a medication no longer covered under the new restrictions. Without an appeals process to access denied medications, these patients could experience worse health outcomes and even death. State Flexibilities NORD opposes a number of proposals in the waiver application considered under the broad moniker of “state flexibilities.” Tennessee is asking to be exempt from federal standards and requirements for its managed care program, including the Managed Care Rule. This important safeguard ensures Medicaid Managed Care Organizations (MCOs) have to meet certain requirements related to patient care. For example, the managed care rule sets standards related to adequate networks, so patients can actually see the appropriate providers and receive the care they need. The managed care rule requires MCOs to comply with standards of time and distance to measure this network adequacy, helping patients access both primary care providers and specialists they need. Tennessee is asking to change the “amount, duration, and scope” of benefits, which could allow the state to put caps on services or only cover critical services for certain individuals. The Medicaid population, by definition is a vulnerable population, allowing Tennessee to change the “amount, duration, and scope” of benefits could impact negatively impact patient care and outcomes. Finally, the state would no longer need to get approval to make changes to benefits and services in the future and would like to make this demonstration permanent, removing important opportunities for the public to provide feedback on the how the program is working for key stakeholders before any policies are implemented or continued. It is especially important that beneficiaries impacted by the demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint venture between Tennessee and CMS. Both entities, as well as the people it serves, should have a voice in how the program is administered. Fiscal Sustainability If Tennessee is truly concerned about the fiscal sustainability of its Medicaid program, the state could submit a state plan amendment to fully expand Medicaid to 138 percent of the federal poverty level and receive a 90 percent match from the federal government for all expenses for the adult expansion population. This policy would both benefit the state financially and extend access to care to more lowincome individuals in need of coverage, a core objective of the Medicaid program. Tennessee has also failed to provide a complete budget neutrality estimate with details of the projected changes in spending with the waiver and any impact on coverage. The federal rules at 431.408 pertaining to state public comment process require at (a)(1)(i)(C) that a state include an estimate of the expected increase or decrease in annual enrollment and expenditures if applicable. The intent of this section of the regulations is to allow the public to comment on a Section 1115 proposal with adequate information to assess its impact. Given that this waiver represents a fundamental change to Tennessee’s demonstration, the state should include these projections and their impact on budget neutrality provisions. The core objective of the Medicaid program is to furnish healthcare to low-income and needy populations. This waiver does not further that goal and NORD opposes the proposal. Thank you for the opportunity to comment on this legislation. For further questions, please do not hesitate to contact me at ddelcarlo@rarediseases.org. Sincerely, /s/ Danielle Del Carlo Director of State Policy                                                              i  Joan Alker. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown University  Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/  pending‐cms‐guidance‐on‐medicaid‐block‐grants‐executive‐overreach‐strikes‐again/.  ii  https://theincidentaleconomist.com/wordpress/tennessee‐wants‐to‐block‐grant‐medicaid‐is‐that‐legal/  Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: FitzGerald, Dawn Wednesday, October 16, 2019 11:35 AM PUBLICE NOTICE TENNCARE Heavrin, Ben [EXTERNAL] Tennessee Block Grant Proposal Comments Qsource Comments on TN Block Grant.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you for this opportunity to provide comment on the proposed amendment to the 1115 demonstration  waiver whereby TennCare would convert its federal share of core population funding to a block grant.  We  appreciate your consideration of our comments.    Sincerely,    Dawn FitzGerald  Chief Executive Officer  Qsource  49 Music Square West, Suite 402  Nashville, TN 37203      T: 866‐514‐8595 ext. 7250  C: 901‐692‐3539  F: 615‐244‐2018  www.qsource.org    1 October 16, 2019 Mr. Gabe Roberts Director State of Tennessee Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Mr. Roberts: Thank you for this opportunity to provide comment on the proposed amendment to the 1115 demonstration waiver whereby TennCare would convert its federal share of core population funding to a block grant. We acknowledge that your submission of this proposed amendment to the Centers for Medicare & Medicaid Services is mandated by Tennessee House Bill 1280, signed into law in May 2019. As you are aware, Qsource is a CMS-contracted quality improvement organization. We also serve as the external quality review organization (EQRO) for the State of Tennessee, Division of TennCare. The Qsource family is a mission-driven enterprise promoting the health and wellbeing of the communities we serve. We value our partnership with TennCare, and we believe we have a strong and mutually beneficial relationship as your designated EQRO. Working as the TennCare EQRO gives Qsource a unique vantage to observe the services provided under the current 1115 waiver. TennCare has a strong reputation as a leader in promoting innovative, high quality and cost effective care within the context of Medicaid managed care. We recognize that the TennCare-contracted health plans also share in a commitment to the health and wellness of its members. The draft of the block grant proposal conveys your intent to carry forward a tradition of innovative health services delivery within TennCare. We applaud the TennCare leadership’s commitment to transformational health delivery innovation where the end result is improved health for our fellow Tennesseans. History teaches us, however, that policymakers must also consider the potential negative and unintended consequences of any new policy change. Clearly, any policy change could have a myriad of potential risks and benefits. While certain stakeholders have politicized changes to the Medicaid program, Qsource provides comment on the block grant amendment in a non-partisan manner. We are a non-profit, mission-driven quality improvement organization eager to support the health and wellness of the communities we serve. Our comments do not convey any speculation on the legality of the block grant structure, nor should they be considered reflective of the block grant proposals of other states. Our comments are not meant to endorse or discourage the block grant proposal itself. Rather, we intend to explore some specific considerations of the program as it relates to a TennCare-specific policy change for the citizens of Tennessee. We believe that the many differences in opinion among block grant stakeholders may reflect the uncertainty involved in being the first state in the nation to apply for such a block grant via state legislation. There is no precedent. Thus, there are questions about financing, eligibility, access, and oversight that are not perfectly clear in this draft. Therefore, we encourage TennCare to continue dialogue with stakeholders - as it is currently doing - both in the formulation of the waiver application and throughout the life of the block grant initiative. In theory, the block grant proposal may lower the federal administrative burden on TennCare, shift certain financial risks to the State, and allow greater flexibilities to innovate within Medicaid managed care. This may allow your agency to leverage market efficiencies that benefit both the State and the TennCare membership. However, as a “first mover” state, the risks of unforeseen consequences may exist, especially when fiscal and macroeconomic forces could play an unknown role in future block-grant related revenue streams and program expenditures. Moreover, while a reduction in federal oversight may prove valuable, we do believe that objective and independent quality assurance within the healthcare marketplace is important. Economists teach us that oversight lessens the burden of an inefficient marketplace. Oversight mechanisms work together with market forces to hold agents of healthcare delivery accountable for their conduct. Oversight mechanisms also deter and prevent fraud, waste, and abuse. These mechanisms address mistakes and oversights should they occur. This is expressly the role of the EQRO. We recognize that your draft proposal is a “hybrid” block grant model, which we find important to highlight in the larger context of this policy change. You do not propose a block grant financing structure for the entire TennCare program. We further recognize the following key concepts in the draft proposal:    There will be no changes in current eligibility or current covered benefits. Certain current funding structures for disproportionate share hospitals, critical access hospitals, and duel eligible beneficiaries will not change. The proposed amendment does not change the current funding structure for outpatient prescription drugs.   The block grant will have a per capita adjustment to compensate for enrollment growth. The funding vehicle will exclude any future newly eligible population covered under TennCare, even if the population is deemed to be a component of the core population. We believe these features important to highlight, as they may lessen the risk that could be inherent in a full and complete block grant structure. A core imperative of the amendment is to increase the flow of federal funds to TennCare based on the current shared savings calculation. Potential increased federal funding to the TennCare program would be of benefit. You also note that the block grant amendment is philosophically not a means to reduce eligibility or benefits, but rather a means to improve value based payment initiatives, member empowerment, and community engagement. We note with enthusiasm that savings from the block grant amendment could be used to improve and expand health care coverage. All these goals are laudable. We recognize that a draft proposal may not have intended to describe in perfect detail the means by which the state will implement improvements and reforms to strengthen the TennCare program. Such detail and the associated timeframes by which these improvement will generate cost savings are nevertheless important to consider. For example, you highlight the potential benefits that come with an improved TennCare formulary bargaining structure, flexibility in modifying covered services for specific TennCare populations, and an investment in rural health infrastructure. These goals, while important, may be difficult to operationalize in the short term. We are eager to see how TennCare overcomes these operational challenges should the amendment receive CMS approval. We recommend that any change in benefits structures needs to occur with comprehensive stakeholder input and an expert understanding of current medical evidence. On a grander scale, we believe some degree of independent oversight or assurance is important. In the economic sense, the healthcare market lacks key drivers of transparency and efficiency. Neither purchaser nor end-user of healthcare goods and services has a perfect understanding of the quality of care provided. Qsource has partnered with TennCare to measure core quality components of the program for some time. As the EQRO, we strongly support quality assurance and quality improvement within the block grant amendment. We know that health insurance and appropriate access to medical services are closely associated with better health outcomes. New treatments and technologies are daily changing the way the medical market prevents illness and treats disease. Yet, any state Medicaid agency must weigh the benefits of novel therapies against the financial realities of serving a vulnerable population via a finite budget. We are confident that, should the block grant amendment pass, TennCare leadership will uphold a highly-valued benefits structure for its members given the theoretically new fiscal realities of the program. Tennessee is on the national stage with its block grant amendment. Qsource thanks you for the opportunity to provide comment. We also thank you for your careful consideration of both the benefits and risks of any fundamental change to a Medicaid program, acknowledging your vision of a healthier Tennessee. Sincerely, Dawn Fitzgerald, MS, MBA Chief Executive Officer Qsource Jonathan Reeve From: Sent: To: Subject: Attachments: Ruth Allen Thursday, October 17, 2019 5:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on Amendment 42 Block Grant Comment Letter Final.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Pleased find our comments attached.    Thank you.    Ruth    Ruth E. Allen Executive Director Tennessee Chapter of the American Academy of Pediatrics P.O. Box 159201 Nashville, TN 37215-9201 Phone: 615-383-6004 Email: ruth.allen@tnaap.org Visit us at: www.tnaap.org  This message and any included attachments are intended only for the addressee(s). Unauthorized review, distribution or copying of this communication is strictly prohibited.   1 P.O. Box 159201, Nashville, TN 37215-9201 Phone: 615-383-6004 • Fax: 615-383-7170 E-mail: info@tnaap.org • Web: www.tnaap.org October 17, 2019 PRESIDENT Deanna Bell, MD Mr. Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 VICE-PRESIDENT Anna Morad, MD Dear Director Roberts, BOARD OF DIRECTORS SECRETARY-TREASURER Jason Yaun, MD FELLOWS AT-LARGE Blake Bergeron, MD, West TN Elizabeth Copenhaver, MD, Middle TN Neil Feld, MD, East TN Suzanne Berman, MD, East TN Carlenda Smith, MD, Middle TN Elisha McCoy, MD, West TN Thank you for the opportunity to provide input on Amendment 42. The TN Chapter of the AAP has serious concerns about this proposal. As you know, children in TN make up 56% of all enrollees in TennCare and CoverKids.) This proposed waiver will disproportionately impact low-income children in Tennessee. LOCAL PEDIATRIC SOCIETY REPRESENTATIVES Jason Yaun, MD, Memphis We have four main areas of concern: the overall block grant amount and per capita adjustment, the potential changes in benefits especially EPSDT, changes to the drug formulary, and lack of independent oversight of the TennCare program. MEMBERSHIP CHAIR Lindsey Wargo, MD Block Grant Amount – Per Capita Adjustment NOMINATING CHAIR Gail Beeman, MD CHAIR, COUNCIL OF PAST PRESIDENTS Gail Beeman, MD EX-OFFICIO MEMBERS PEDIATRIC DEPARTMENT CHAIRS Xylina D. Bean, MD, Meharry Charles Woods, MD, UT Chattanooga Jon McCullers, MD, UT Memphis Steven Webber, MBChB, MRCP, Vanderbilt Dawn Tuell, MD, MPH, ETSU Acting Chair PAST PRESIDENTS (* Deceased) Gail Beeman, MD. (2016-17) Michelle D. Fiscus MD (2014-15) R. Allen Coffman, Jr., MD (2012-13) Eddie D. Hamilton, MD (2010-11) John R. Hill, MD (2008-2009) Quentin A. Humberd, MD (2006-07) David K. Kalwinsky, MD (2004-2005) John C. Ring, MD (2002-2003) Joseph F. Lentz, MD (2000-2001)* Iris G. Snider, MD (1998-1999)* Russell W. Chesney, MD (1995-97)* Harold F. Vann, MD (1992-94) Hays Mitchell, MD (1989-91) Bobby C. Higgs, MD (1986-88) Luthur A. Beazley, MD (1983-85)* George A. Zirkle, Jr., MD (1980-82)* Walton W. Harrison, MD (1977-79)* Felix G. Line, MD (1974-76)* EXECUTIVE DIRECTOR Ruth E. Allen Our first concern is how the block grant amount will be calculated, using the average enrollment over the most recent state fiscal years. As you know, there has been a significant drop in children’s enrollment since 2016. The TN AAP has been in conversation with the TennCare Bureau regarding these concerns. We continue to hear from member practices about numerous instances where children have lost coverage but should be eligible. We will continue to work with the Bureau to address this problem. As it pertains to this block grant proposal, we are worried that the state could be underestimating the true number of TennCare eligible children and therefore will not receive the appropriate amount of funds needed to provide care to these kids. We are also concerned that the block grant amount assumes that all beneficiaries will maintain the current level of need over the course of the waiver. While the proposal does account for the potential of exceeding the average enrollment numbers for any one category of beneficiary by adjusting the cap, this does not result in additional federal funds for care of the existing enrollees. If there is a measles outbreak, if there is a need for additional services to treat opioid use disorders, or if there are new treatment innovations, how will the state deal with overruns in costs that are not due to increased enrollment? We are concerned this could result in benefit cuts for children. Director Roberts Page 2 Potential Changes to Benefits –Including EPSDT In this proposal, the state touts its need for flexibility and freedom from federal requirements, which would include the ability to vary benefit packages by limiting the amount, duration, and scope of core benefits. Pediatricians in TN are concerned as to what this would mean for children and the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit which states are currently required to provide all children enrolled in Medicaid.1 As the state continues to stress that there is no intent to limit or change any benefits, we request that the language on page 20 of the waiver proposal which reads, “The state proposes that it have the flexibility under this demonstration to make changes to its benefits package, including the addition or elimination of optional benefits and changes in the amount, duration, and scope of covered benefits, without the need for CMS approval” be removed. This language, and lack of federal oversight, regarding the provision of Medicaid benefits only serves to provide the state with the option to reduce or limit services to children. Children are constantly growing and developing and as pediatricians we know the importance of seeing children and adolescents on a regular basis to support their ongoing needs. While we understand the current intent of this waiver proposal is not to reduce covered benefits below their current level, Tennessee pediatricians want to ensure that TennCare is committed to maintaining EPSDT. As physicians who treat children, we understand the importance of children receiving important preventive services that serve to identify and treat any health conditions early on, preventing them from being more significant, and ultimately being more costly to treat. We want to ensure that kids continue to receive all services that we as pediatricians determine to be medically necessary. Drug Formulary As currently proposed, the state has requested that TennCare have a closed drug formulary with as few as one drug per therapeutic class. Additionally, the state is asking, in part, to not be required to cover drugs without significant medical evidence which demonstrates effectiveness. A closed formulary would be in violation of the Medicaid EPSDT guarantee for children by not adhering to Tennessee’s responsibilities to ensure that all children receive medically necessary treatment. EPSDT guarantees that all Medicaideligible children are screened to assess and identify problems early and ensures that Medicaid provides all medically necessary health services to correct or ameliorate those problems, including the provision of prescription drugs. And again, we are concerned about the state maintaining the EPSDT benefit under this proposal. This change will also significantly limit access to medication that children require to be healthy, as the state is proposing the ability to exclude drugs until such time as the state believes there is adequate medical evidence of a clinical benefit. Two federal laws, the Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA), have resulted in enormous strides in our understanding of the safe and effective use of medicines in children, with a significant increase in drug labeling for the pediatric population. However, off-label use of medication in children remains a necessary, component of a pediatric practice. One half of drugs still have no FDA approved labeling for use in children. For special child populations, such as preterm and full-term neonates, infants and children younger than 2 years, and children with chronic or rare diseases, off-label use of drugs is significant.2 Additionally, as currently drafted, there is no appeals process noted for beneficiaries who may have a medical need for drugs that are not covered. This leaves families without access to treatment for their children that a physician has deemed medically necessary. 1 2 https://www.medicaid.gov/medicaid/benefits/epsdt/index.html https://pediatrics.aappublications.org/content/133/3/563 Director Roberts Page 3 Oversight While this proposed waiver argues that the state should be free from federal oversight, there is nothing in it that indicates any mechanism for oversight within the state. TennCare stakeholders should continue to have the opportunity to offer comments or concerns regarding possible program changes. Will the state continue to have open comment periods for any future programmatic changes, such as alterations to benefits packages, enrollment procedures, or the use of federal block grant dollars on alternative public health programs outside of TennCare? We are concerned that the state is seeking unilateral control of TennCare without seeking input from individuals who are serving these low-income beneficiaries on the ground and have in depth knowledge of their needs. As one of many stakeholder groups with a vested interest in continuing to have a TennCare program that effectively serves the low-income residents of this state by providing much needed health care coverage, we encourage the state to implement some type of oversight for changes being made to the program. In addition, we suggest formation of an advisory board which would include medical providers and other key stakeholders. Thank you for the opportunity to comment on this proposed waiver. As pediatricians, we can offer our insight into the specific health care needs of children, which vary from the needs of adults, and how any potential changes could impact the majority of TennCare enrollees and their families. We hope the state takes the thoughts of Tennessee’s pediatricians into consideration as it considers approval of this waiver. If you have any questions regarding our concerns, please contact Ruth Allen, TNAAP Executive Director, at ruth.allen@tnaap.org or 865-310-3421. Sincerely, Deanna Bell, MD President Jonathan Reeve From: Sent: To: Subject: Attachments: Debi Gonzalez Thursday, October 17, 2019 2:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment on Proposed Amendment 42 TNCO Amendment 42 Comments.docx; PastedGraphic-3.tiff   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dr. Roberts,    Thank you for your consideration of TNCO Comments to proposed Amendment 42 attached.    Best,    Debi      -Debi Alvey Gonzalez, M.S., BCBA Operations Director - Adult Services Phone: (615) 945-2113 Fax: 1-888-800-7610 Email: debigonzalez@millarrich.com www.MillarRich.com   Disclaimer: This e-mail may contain PRIVILEGED and CONFIDENTIAL information and is intended only for the use of the specific individual(s) to which it is addressed. If you are not an intended recipient of this e-mail, you are hereby notified that any unauthorized use, dissemination or copying of this e-mail or the information contained in it or attached to it is strictly prohibited. If you have received this e-mail in error, please delete it and immediately notify the person named above by reply e-mail. Thank you.     1 Tennessee Community Organizations 40 Rutledge St. Nashville TN, 37210 T 615.736.6090 or 877.265.2064 F 615.736.6095 W tnco.org Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Donald Redden, President Robin Atwood, Executive Director Dear Director Roberts, I am submitting the following comments regarding the proposed Amendment 42 to convert federal funding for TennCare into a block grant. My name is Debi Gonzalez, and I work with one of many agencies providing long term services and supports for Tennesseans with intellectual and developmental disabilities that live in urban and rural communities across all areas of this beautiful state. I am sending comments on behalf of Tennessee Community Organizations (TNCO) that represents provider agencies across all 3 regional areas of Tennessee. We greatly appreciate your time in considering the following comments: • • • • • We are pleased that the individuals being served under the 1915 waivers within the Department of Intellectual and Developmental Disabilities are exempt as we feel the individuals being served under these waivers will continue to need the level of assistance and support they have been receiving given their unique needs. We are concerned that the individuals being served under the ECF CHOICES and CHOICES waivers may be unduly exposed to decreases in the services they need, and that this may prove to be a barrier for the waiting list that ECF CHOICES has been developed to address. The rates for CHOICES and ECF CHOICES could be negatively impacted by this change which would continue to place hardship on the providers directly supporting the individuals served, and thus, the individuals directly. CHOICES and ECF CHOICES should be expanding with additional people being able to receive services as Tennessee continues to promote the HCBS Settings Rule. We are excited and agree with investing in Health, not just healthcare, but feel that there should be more specifics around what types of health outcomes would be targeted with parameters for how this would be monitored and measured. Given the importance federal oversight has historically played in ensuring that individuals with intellectual and developmental disabilities receive the services that they need, we do feel that some type of oversight is important but understand the burden of annual oversight. We recommend that this demonstration be reviewed every 3 years, or at a minimum of every 5 years. The 50/50 savings proposal for our state to receive 50% of the savings from any spending less than the block grant allotment could be an innovative win for Tennessee. • • • Given the DSP staffing shortage, and our state’s commitment to competitive DSP wages, we recommend that a portion of these savings go directly to DSP wages. Based on the unique medical needs of the individuals served in the ECF CHOICES and CHOICES waivers, we request a medical necessity exemption be included for the individuals to be able to get a needed medication off of the formulary. Medications should not be restricted for the people receiving these services, but if any restrictions are implemented, there should be an appeals process for the individuals served. We support the initiative behind bringing more infrastructure to rural healthcare and would like to ensure that this infrastructure includes continued funding toward broadband for EVV and other technological approaches to services while also allowing flexibility for manual confirmations for services where broadband may not be available. The approach Tennessee recommends to the Katie Beckett and other new LTSS waivers to ensure adequate funding during the initial 3 years of implementation seems reasonable. However, the Katie Beckett waiver is so important to families with children with significant needs, we do want to be sure that the program and others like it are sustainable and have every opportunity to grow as needed to meet the needs of Tennesseans. Sincerely, Debi Gonzalez TNCO Regulatory Committee Page 2 Jonathan Reeve From: Sent: To: Subject: Attachments: Andrew Smith Wednesday, October 16, 2019 9:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment on TennCare block grant proposal TennCare block grant proposal.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Hello,    Please see the attached comment.    Thank you,    Andrew Smith, MSW, MPH  Community Engagement Manager  Depression and Bipolar Support Alliance  312‐988‐1183  We've Been There. We Can Help.    1 October 11, 2019 The Honorable Bill Lee Office of the Governor 600 Charlotte Ave Nashville, TN 37243 Dear Governor Lee, I am writing regarding the block grant proposal around TennCare. This proposal will affect access to mental health treatment for over 1 million vulnerable Tennesseans the program covers, especially those with low-income living with mental health conditions. These serious, all too often life-threatening—yet highly treatable—conditions combine to cost $23 billion in work absenteeism and account for 90 percent of the nation’s suicides. The Depression and Bipolar Support Alliance (DBSA) is the leading national peer-directed organization focusing on mood disorders reaching over 1,000 Tennessean’s through the DBSA TN state organization and 11 chapters across the state. DBSA works to change the conversation around the issue of mental health through our mission to provide hope, help, support and education to improve the lives of people who have mood disorders. The opportunity to lead a thriving life begins with hope and for many continues with access to quality mental health care that meets individualized needs. Depression is the number one cause of disability in the United States. Yet people living with mood disorders can and do lead quality productive lives when they have access to quality mental health services and products. Case in point, one study showed disability days for people experiencing severe depression are reduced by 36% once they improve and those experiencing moderate depression saw a reduction in disability days by 72%.1 Investing in mental health is sound fiscal policy. Every $1 invested in expanded treatment for depression and anxiety leads to a $4 return in better health and enhanced labor participation and productivity.2 Additional studies demonstrate that the presence of active behavioral health treatment reduces a patient’s overall medical costs by 17% compared to control groups who did not receive care. Further, those in the control group actually saw health care costs rise by 12.3%.3 When treating mood disorders, one size does not fit all. DBSA encourages TennCare to provide beneficiaries a clear appeals process and consumer protections for any changes made to their prescription drug formulary. ● ● ● ● The proposed waiver could put coverage at risk for people living with severe and persistent mental health conditions by capping federal Medicaid funding. Further, this strategy could expose Tennessee to financial risk if per-person TennCare costs grow substantially faster than expected, as could occur in a public health crisis (such as the opioid crisis) or due to innovations in medical treatment. As I have outlined above, it makes sense fiscally to invest in mental health instead of cutting services, not only for the state budget, but also for the economy. That includes access to quality mental healthcare and medical products. Please do not move forward with block grant proposal as it is. Tennessean’s need guarantees of access, which in turn, will create a much healthier and productive state with far greater savings. Sincerely, Phyllis Foxworth Advocacy Vice President Depression and Bipolar Support Alliance Daisy Jabas President DBSA Tennessee State Organization 1. Von Korff, Ormel, Katon & Lin. Archives of General Psychiatry. February 1992. 2. Chisholm, et al. Lancet Psychiatry. April 12, 2016. 3. Chiles, Lambert & Hatch. Clinical Psychology Science and Practice. June 1999. ● ● ● ● Jonathan Reeve From: Sent: To: Subject: Attachments: Don Clayback Friday, October 18, 2019 4:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments Re TennCare II Demonstration: Amendment 42 Draft NCART Comments TennCare Block Grant 10-18-19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please see attached.  Thank you.     Donald E. Clayback  Executive Director   NCART  716‐839‐9728 (office)   716‐913‐4754 (cell)  dclayback@ncart.us   www.ncart.us      1       October 18, 2019    Submitted electronically at public.notice.tenncare@tn.gov     Director Gabe Roberts  Division of TennCare  310 Great Circle Road  Nashville, TN 37243    Re: TennCare II Demonstration: Amendment 42 Draft    Dear Director Roberts,    The following comments are submitted on behalf of the National Coalition for Assistive and Rehab  Technology (NCART).  NCART is a national association of manufacturers and suppliers of Complex Rehab  Technology (CRT) products with multiple supplier and manufacturer member locations in Tennessee.    Our members have decades of experience leading the development and provision of CRT products  designed to address the medical and functional needs of people with significant disabilities. NCART’s  mission is to ensure individuals with disabilities such as ALS, cerebral palsy, spinal cord injury, multiple  sclerosis, muscular dystrophy, spina bifida, and traumatic brain injury have adequate access to the CRT  products and related services they require to address their identified needs.      CRT products include medically necessary  and individually configured manual and power wheelchairs,  seating and positioning systems, and other  adaptive equipment.  The proper provision of this specialized  equipment is done through a service‐intensive process that requires an evaluation by knowledgeable  physical and occupational therapists, a technology assessment, configuration, fitting, adjustment, and  programming.  Once delivered, these items need to be supported with ongoing adjustments,  modifications, and maintenance.      Adequate access to CRT is a critical, but often unrecognized, requirement to successfully meeting the  medical and functional goals of people with disabilities.  CRT products have the capability to  ameliorate or mitigate identified medical and functional needs resulting in improved outcomes and  reductions in the overall cost of care.  Our strong belief in CRT as a critical component in any plan of  care for a person with a disability to ensure the best possible outcomes is the basis for our letter.    NCART appreciates the opportunity to provide the following comments on the Amendment 42 Draft,  Tennessee’s proposal to convert the federal share of its Medicaid funding relating to providing its core  medical services to its core population to a block grant:    1.) We are supportive of initiatives within our national healthcare system to improve the efficiency and  quality of healthcare while at the same time managing related healthcare costs.  As the draft      54 Towhee Court, East Amherst, New York, 14051     716‐839‐9728     www.ncart.us  October 18, 2019                                                                                                                                               Page 2  2.) 3.) 4.) 5.) 6.) 7.) 8.) proposal notes, the important factor in pursuing this goal is to accomplish it “without compromising  access to or quality of care”.    While we understand this is a draft proposal, there are significant details that will need to be further  developed in order to fully evaluate the potential opportunities and risks associated with a block  grant program.  Our comments identify some of the necessary information that will need to be  provided in the future.    The children and adults who are served by our CRT suppliers in the State represent a high risk and  high need TennCare population that is classified in the draft proposal as the “disabled” member  category.  Given the high healthcare risks and costs that are associated with these enrollees it is  critical for the State to ensure that proper coverage and payment policies are in place to provide  adequate access to timely equipment provision and service from qualified CRT suppliers.    We have concerns with the references to the significant reductions in CMS oversight being sought in  the draft proposal under the request for “flexibility from excessive or unnecessary federal  intervention”.  While we agree there should not be excessive or unnecessary intervention, there is a  need for reasonable CMS oversight to ensure adequate enrollee coverage and access.    We have concerns with the request that the state “have the flexibility under this demonstration to  make changes to its benefits package, including the addition or elimination of optional benefits and  changes in the amount, duration, and scope of covered benefits, without the need for CMS  approval” (page 20).  In 42 CFR § 440.230 sufficiency of amount, duration, and scope is set as a  minimal requirement, not as a limit.  We do not agree with the elimination of the current  requirement for the submission and CMS approval of State Plan Amendments (SPA) or  demonstration amendments.  While we understand the State will need certain flexibility in the  operation of the block grant, as mentioned above a level of CMS oversight and interaction must be  maintained.    We have concerns with the request for “exemption from any new federal mandates during the  demonstration” (page 11).  We suggest that rather than an exemption from new mandates that the  block grant should establish a process and formula for the State to seek additional payments  resulting from the new mandate.    We recommend that language be included to describe how TennCare would measure, monitor, and  manage enrollee access under the block grant program.  This should include provisions covering: (a)  what metrics will be measured, (b) how and when they would be reported, (c) opportunities for  public comment on proposed changes, and (d) the system and timelines for evaluating and resolving  access issues when they are reported.    We have concerns that without proper block grant program safeguards and monitoring the financial  incentives for the State (the state retaining 50% of any “savings”) could create unintended negative  incentives for program and service reductions that would negatively impact enrollees with  significant disabilities.  This underscores the need for adequate safeguards and oversight.    October 18, 2019                                                                                                                                               Page 3  9.) Our members support the need to ensure that all Tennessee enrollees have access to the healthcare  services, programs, and equipment they require. We believe program policies and guidelines under  a block grant should ensure adequate and timely access, promote innovation that improves  outcomes, and effectively manage overall healthcare costs.      We strongly recommend that in the course of developing the final block grant program provisions the  State meet with CRT stakeholders (enrollees, clinicians, suppliers, manufacturers, others) to ensure  there are no access barriers or other negative outcomes to this vulnerable population.  Preserving  proper coverage and payment policies for this specialized equipment and its supporting services is of  utmost importance to the community of people with disabilities and to the State’s goal of reducing  healthcare costs.    NCART members are willing and have the expertise needed to assist in developing appropriate policies  that protect both the TennCare program and access to the important CRT products and services for  TennCare enrollees with significant disabilities.  Thank you for your serious consideration of the above  comments and recommendations.      Sincerely,      Donald E. Clayback        Executive Director        716‐839‐9728          dclayback@ncart.us   www.ncart.us                      Jonathan Reeve From: Sent: To: Subject: Attachments: Doria Panvini Friday, October 18, 2019 10:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on Block Grant proposal Amendment 42 dp2.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Roberts: As a parent of a son with intellectual disability and as a member of a board of a small non-profit agency supporting people on both the DIDD and ECF CHOICES programs, I oppose Amendment 42. My son, Chris, has intellectual disability and receives Medicaid Waiver services through the DIDD waiver as well as Medicaid for his health care. Amendment 42, as proposed, could make significant negative changes to the supports and services currently available through both Medicaid healthcare and to Chris’s and others long term supports and services. These essential services allow people with intellectual and developmental disabilities (I/DD) to continue to live in their community with their families or with supports from agencies when their families are no longer able to support them and to have healthcare that meet their needs, including appropriate medications. I have read Amendment 42 several times and, therefore, do NOT believe I am “misinformed” as said by Governor Lee. From both the perspective as a parent and as a board member, I do understand the impact of the block grant proposal. Therefore, I oppose Amendment 42 based on the issues below. A closed drug formulary will drastically impact many people with I/DD. Chris takes psychotropic medications and over the years his drugs have changed and improved. The newer and at times more expensive medications have been more effective as well as safer with fewer side effects. Anyone who would have to change their drugs because of the closed formulary, could have increased behavioral or emotional issues. One size does not fit all. This is equally true for all other classes of drugs. Whether a person has an allergy to an ingredient in the drug or the chosen drug just doesn’t work for them, this could mean a significant negative impact on a person’s health. No one should have to wait through an appeals process for a drug that needs to be taken immediately. A closed formulary will leave many at risk. A premise of Amendment 42 is that there will be “savings” based on the lack of spending on the part of TennCare paired with savings of the federal government. Instead of using these savings to address the needs of those eligible for TennCare, it is to use funding for other services that MAY impact people with TennCare, but will also provide services for those not eligible for TennCare, Housing 1 supports, nutrition, etc. are worthy causes but not at the expense of services to thousands waiting for services.  Approximately 7000 people with I/DD are on the “referral” list for the Employment and Community First (ECF) CHOICES program. All are eligible for this Medicaid program but there are no “slots” available. The only way to get ECF CHOICES services is when they qualify for emergent needs (crisis) category due lack of a caregiver or because or significant behavioral issues.  Over 100,000 children lost their TennCare due in many cases to administrative errors. There seems to be no apparent effort to reach out to these families to ensure that eligible children are reenrolled in TennCare. Rather than diverting these savings, these unmet Medicaid needs should be covered. Healthcare for everyone eligible should be a priority under Medicaid before funding is diverted to other programs Amendment 42 proposes to have the flexibility to add or eliminate optional benefits and to change the amount, scope, and duration of covered benefits without the need for CMS approval, i.e. without any oversight or input from those impacted by these changes. To people with I/DD these Long Term Supports and Services in the community are essential, not optional, as the only programs available when their families are not no longer able to care for them. But you are saying that you want to be able to make changes or even eliminate benefits without anyone knowing. This would put our most vulnerable citizens at risk. In Amendment 42 you state how efficient and effective TennCare is and how well programs are administered. However, from the perspective of a board member we have seen that every time TennCare changes provider payment processes it takes up to 2 years for the payments to be smoothly and accurately paid. When the payments moved from DIDD to TennCare it was two years of uneven and inaccurate payments. Patient Liability was implemented almost 2 years ago and in that time the agency has had money taken out for patient liability, reimbursed to the agency (twice in 2 years) and then recouped again from the agency because of TennCare errors. It is difficult to see how converting to the block grant will be handled smoothly without disruption to provider payments. For these reasons, I oppose Amendment 42. This Amendment is vague and lacks transparency. If implemented, both healthcare and long term services and supports for people with I/DD could be at risk and no one would know until it was too late. We and our family members deserve better. Thank you for the opportunity to comment on Amendment 42. Sincerely. Doria Panvini Doria Panvini  2 200 Stokesboro Court  Nashville, TN 37215  phone: (615) 292‐9122  mobile:(615) 504‐5836  3 Dear Mr. Roberts: As a parent of a son with intellectual disability and as a member of a board of a small nonprofit agency supporting people on both the DIDD and ECF CHOICES programs, I oppose Amendment 42. My son, Chris, has intellectual disability and receives Medicaid Waiver services through the DIDD waiver as well as Medicaid for his health care. Amendment 42, as proposed, could make significant negative changes to the supports and services currently available through both Medicaid healthcare and to Chris’s and others long term supports and services. These essential services allow people with intellectual and developmental disabilities (I/DD) to continue to live in their community with their families or with supports from agencies when their families are no longer able to support them and to have healthcare that meet their needs, including appropriate medications. I have read Amendment 42 several times and, therefore, do NOT believe I am “misinformed” as said by Governor Lee. From both the perspective as a parent and as a board member, I do understand the impact of the block grant proposal. Therefore, I oppose Amendment 42 based on the issues below. A closed drug formulary will drastically impact many people with I/DD. Chris takes psychotropic medications and over the years his drugs have changed and improved. The newer and at times more expensive medications have been more effective as well as safer with fewer side effects. Anyone who would have to change their drugs because of the closed formulary, could have increased behavioral or emotional issues. One size does not fit all. This is equally true for all other classes of drugs. Whether a person has an allergy to an ingredient in the drug or the chosen drug just doesn’t work for them, this could mean a significant negative impact on a person’s health. No one should have to wait through an appeals process for a drug that needs to be taken immediately. A closed formulary will leave many at risk. A premise of Amendment 42 is that there will be “savings” based on the lack of spending on the part of TennCare paired with savings of the federal government. Instead of using these savings to address the needs of those eligible for TennCare, it is to use funding for other services that MAY impact people with TennCare, but will also provide services for those not eligible for TennCare, Housing supports, nutrition, etc. are worthy causes but not at the expense of services to thousands waiting for services.  Approximately 7000 people with I/DD are on the “referral” list for the Employment and Community First (ECF) CHOICES program. All are eligible for this Medicaid program but there are no “slots” available. The only way to get ECF CHOICES services is when they qualify for emergent needs (crisis) category due lack of a caregiver or because or significant behavioral issues.  Over 100,000 children lost their TennCare due in many cases to administrative errors. There seems to be no apparent effort to reach out to these families to ensure that eligible children are reenrolled in TennCare. Rather than diverting these savings, these unmet Medicaid needs should be covered. Healthcare for everyone eligible should be a priority under Medicaid before funding is diverted to other programs Amendment 42 proposes to have the flexibility to add or eliminate optional benefits and to change the amount, scope, and duration of covered benefits without the need for CMS approval, i.e. without any oversight or input from those impacted by these changes. To people with I/DD these Long Term Supports and Services in the community are essential, not optional, as the only programs available when their families are not no longer able to care for them. But you are saying that you want to be able to make changes or even eliminate benefits without anyone knowing. This would put our most vulnerable citizens at risk. In Amendment 42 you state how efficient and effective TennCare is and how well programs are administered. However, from the perspective of a board member we have seen that every time TennCare changes provider payment processes it takes up to 2 years for the payments to be smoothly and accurately paid. When the payments moved from DIDD to TennCare it was two years of uneven and inaccurate payments. Patient Liability was implemented almost 2 years ago and in that time the agency has had money taken out for patient liability, reimbursed to the agency (twice in 2 years) and then recouped again from the agency because of TennCare errors. It is difficult to see how converting to the block grant will be handled smoothly without disruption to provider payments. For these reasons, I oppose Amendment 42. This Amendment is vague and lacks transparency. If implemented, both healthcare and long term services and supports for people with I/DD could be at risk and no one would know until it was too late. We and our family members deserve better. Thank you for the opportunity to comment on Amendment 42. Sincerely. Doria Panvini Jonathan Reeve From: Sent: To: Subject: Attachments: Elisa Hertzan Monday, October 14, 2019 3:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare II Demonstration Amendment 42 “Block Grant Waiver” Blockgrant Comments .pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good afternoon:    Attached please find comments from the Epilepsy Foundation of Middle and West TN concerning the above Block Grant  Waiver.     Respectfully submitted,     Elisa Hertzan   Executive Director  Epilepsy Foundation of Middle and West Tennessee  701 Murfreesboro Pike Suite 200  Nashville, TN 37210  615.269.7091  Director@EpilepsyTn.org  www.epilepsytn.org    1 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Yarnell Beatty Wednesday, October 16, 2019 7:12 AM PUBLICE NOTICE TENNCARE Gabe Roberts; Russ Miller; Dave Chaney; 'elise denneny' [EXTERNAL] TMA Block Grant Waiver Comments_Final_10152019.docx TMA Block Grant Waiver Comments_Final_10152019.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Gabe,    Good morning. Please find attached comments on the TennCare Waiver Amendment 42  proposal filed on behalf of the Tennessee Medical Association.     Look forward to your presentation at the Health Law conference this week.     Best regards,    ‐Yarnell‐    Yarnell Beatty, JD  Senior Vice President and General Counsel  Tennessee Medical Association  T: 615‐460‐1644   800‐659‐1862  F: 615‐312‐1897            1     October 16, 2019          Mr. Gabe Roberts, Director, Division of TennCare  310 Great Circle Road  Nashville, TN 37243  public.notice.tenncare@tn.gov       Dear Mr. Roberts:    The Tennessee Medical Association (TMA) and its more than 9,000 members hereby submits the  following comments on the Draft TennCare II Demonstration Project No. 11‐W‐00151/4 (Waiver  Amendment  42).  Waiver  42  outlines  Tennessee’s  proposal  to  convert  the  federal  share  of  its  Medicaid funding relating to providing its core medical services to its core population to a block  grant.  TMA  has  generally  supported  the  idea  of  using  block  grants  or  a  per‐capita  allotment  for  TennCare. If adequately designed, funded, and implemented, the additional flexibility could allow  Tennessee to administer a more efficient and effective Medicaid program, without burdensome  and  costly  federal  requirements.  There  are  some  positives  so  far  in  the  preliminary  waiver  request, such as the potential to transform rural healthcare through electronic consultation and  telemedicine.  If  the  federal  government  ultimately  wants  to  reduce  funding  from  current  levels  and  if  the  design and implementation of the program do not reduce administrative and clinical barriers to  care delivery by physicians, access and quality of care will struggle. This is because the state will  be unable to even maintain current TennCare levels without changing eligibility requirements or  cutting benefits, or being able to boost physician participation to a higher level.  The Draft raises more questions than it answers at this point. TMA is unable to determine at this  time whether the State’s proposal can realistically improve healthcare access and quality while  reducing cost. We expect the TennCare Bureau and Governor Lee’s administration to be judicious  in the ensuing negotiations with CMS, and TMA hopes that they will engage the physicians who  actually deliver care to our state’s most vulnerable patient population if this is to be successful.  TMA  stands  ready  to  help  with  strategies  to  maximize  value‐based  care  through  creation  of  coordinated team‐based delivery systems.  As block grants are debated, some of TMA’s core principles should be considered as part of any  federal healthcare reforms impacting how TennCare is funded and/or administered:      o We  support  a  competitive  insurance  market  that  includes  both  public  and  private  choices,  with  access  for  all  patients  regardless  of  preexisting  conditions,  and  the  freedom for patients to choose their own physicians.   o We believe physicians should be able to determine the most appropriate and cost‐ effective care for each patient, and in eliminating bureaucracy and mandates that tie  physicians’ hands.  o We  believe  in  strengthening  patient‐physician  relationships  though  medical  home  programs.  o We  support  strategies  to  lower  the  cost  of  medical  care  through  the  use  of  technology, evidence‐based best practice measures, and liability reforms.  o We  support  strategies  to  increase  access  to  care  through  physician  manpower  expansion  (including  adequate  education  and  training  programs  for  primary  care  physicians), medical student debt relief and fair payment for physicians.     Specific comments and questions about the current block grant Waiver 42 proposal:    Shared Savings:     TMA requests more information as to how savings to the state from a block grant will be  realized. TMA needs more explanation as to why the state proposes to compare costs  under  a  block  grant  to  projected  costs  without  the  1115  demonstration  waiver  to  determine savings. Why instead will it not compare costs under a block grant to projected  costs of the current version of the 1115 demonstration waiver (TennCare II)?  After all,  TennCare has operated for 25 years. The real question is what does the Medicaid health  care delivery system gain in terms of savings due to a change from the current program  to a block grant?     The state proposes to continue its existing episodes of care reform efforts pursuant to the  present State Innovation Model (SIM) grants. TMA takes the position that the TennCare  episodes of care program has serious design flaws, most notably because it financially  penalizes physicians for costs beyond their abilities to control. It should not continue, at  least in its present form. TMA finds it disingenuous for the state to claim as it does on  page 10 of the Draft that, “Any serious effort to reform Medicaid financing must recognize  the  role  of  states  as  equity  partners  with  the  federal  government  in  the  financing  of  Medicaid  and  re‐align  incentives  so  that  states  are  rewarded,  not  penalized,  for  effectively managing the cost of care (while still maintaining access and quality)” when  physicians are eligible for reward, but also penalized for episode costs they cannot control  in attempting to effectively manage health care costs under the episodes of care program.       In what ways will physicians directly benefit from savings realized pursuant to Waiver 42  if it is approved? Will reimbursement levels for physicians increase? TennCare enrollees  may have difficulty finding primary care providers and specialists if the Bureau does not  improve reimbursements and administrative requirements for those providers.  2          Per Capita Adjustment   The block grant amount assumes that all enrollees will maintain their current level of need  over the course of the waiver. While the proposal accounts for the potential of exceeding  the average enrollment numbers for any one category of beneficiary by adjusting the cap,  there does not appear to be a mechanism by which to increase funding for care of the  existing enrollees when needs arise that are not due to increased enrollment but due to  changes in health conditions.    Excluded Expenditures:     The state is asking for exclusion for expenditures that are outside of its control. By the  same logic, this same courtesy should be extended to physicians by way of modifications  to the episodes of care program so that costs over which they have no reasonable control  are not attributed to them for purposes of being financially penalized. Waiver 42 indicates  the state will continue the episodes of care program as a mechanism by which to achieve  savings.      TMA is very concerned about the level at which TennCare will pay its fair share for dual  Medicare‐Medicaid eligible enrollees. The state has failed to pay its share of expenses for  health care services as a secondary payer after Medicare pays its 80% allowable amount.     Avoiding Disincentives for Future Program Changes:     The  state  is  requesting  exemption  from  new  federal  mandates  that  have  a  material  impact  on  the  state’s  Medicaid  expenditures  (e.g.,  mandates  concerning  eligibility  or  covered benefits). Will physicians receive relief from administrative burdens imposed by  federal mandates or those imposed by the TennCare program design or managed care  organizations?    Closed Formulary:     Having only one drug per therapeutic class is dangerous. There needs to be a mechanism  for patients that may be intolerant, allergic, or have tried and failed a particular drug, to  have access to appropriate treatment without a burdensome prior authorization process  for physicians.     Off‐label  use  of  medication  is  an  unfortunate,  yet  necessary,  component  of  medical  practice. For example, one half of drugs still have no FDA approved labeling for use in  children. For special child populations such as preterm and full‐term neonates, infants  and children younger than 2 years, and children with chronic or rare diseases, off‐label  use of drugs is significant. The FDA simply is not agile enough to address legitimate clinical  efficacy  of  off  label  use.  TMA  objects  to  any  plans  under  a  block  grant  that  exclude  payment for the use of medically necessary off‐label drugs that work for patients.     3          TMA  seeks  more  information  as  to  the  impact  of  the  closed  formulary  on  the  current  EPSDT  requirement.  We  would  object  to  any  change  that  would  jeopardize  the  EPSDT  program.     There does not appear to be an appeals process for enrollees who may have a medical  need for drugs that are not covered. This leaves patients without access to treatment that  a physician has deemed medically necessary.  Leveraging Medicaid as a Catalyst to Promote Rural Healthcare Transformation:     Will  “adopting  technologies”  include  electronic  claim  submission?  Currently,  TennCare  requires the submission of claims by physicians for payment to be submitted by paper.  There has been a pervasive issue with MCO OCR scanners not being able to read some  paper claims, leading to delays and denials. Funds should finally be directed to resolve  technological problems that slow down the process.     Appropriately Penalizing Member Fraud:     TMA  agrees  with  the  proposal  in  Waiver  42  that  enrollees  should  be  penalized  for  committing TennCare fraud; however, there is no financial protection for physicians who  treat  those  patients.  Physicians  who  legitimately  treat  these  patients  should  not  have  their payments recouped for reasons beyond their control due to fraud perpetrated by  enrollees.     Pathway to Permanency:     TMA  is  concerned  that  there  would  be  no  oversight  of  the  state’s  Medicaid  program.  TennCare  should  be  accountable  for  how  they  utilize  resources  and  treat  physicians.  Renewal every five years would be acceptable.    Improving Administrative Efficiency:     There is much discussion regarding meeting the needs of state residents and optimizing  effectiveness and efficiency. TMA hopes to be engaged in the discussion of maximizing  workflow  efficiencies.  Will  this  flexibility  and  reduction  of  administrative  burden  be  passed on to physicians?    Thank  you  for  the  opportunity  to  submit  comments  on  Waiver  42.  TMA  hopes  that  the  implementation of a block grant does not impact our ability to provide stakeholder input into the  program.     Sincerely,    Elise Denneny, MD  President, Tennessee Medical Association  4    Jonathan Reeve From: Sent: To: Subject: Attachments: Ellyn Wilbur Tuesday, October 15, 2019 2:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant Application Tenncare Block Grant comments.doc   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   TAMHO’s comments are attached.                               Ellyn Wilbur Executive Director    Follow us on Facebook!  Tennessee Association of Mental Health Organizations 42 Rutledge Street Nashville, TN 37210-2043  ewilbur@tamho.org  www.tamho.org  (615) 244-2220, ext.12 (800) 568-2642 toll free in TN (615) 254-8331 facsimile We are vitally concerned with your privacy on the internet. If you wish to be omitted from future distributions, please contact us at optout@tamho.org or by phone at 615-244-2220 or toll free in Tennessee at 800-568-2642. Your email address will be purged permanently from this database. We take part in responsible email marketing and respect your right to refuse any other email distributions.   1 October 15, 2019    TAMHO is the state trade association representing community behavioral health providers in Tennessee. Our  members are the cornerstone of the TennCare provider network for individuals with mental health and substance use  disorders and in any given month, 70,000 individuals are seen by TAMHO members.    TAMHO followed the legislation passed by the General Assembly very closely and was pleased to see the protections  put in the bill to ensure that the Tennessee block grant application will not limit the federal government’s financial  participation.  Leadership at TennCare has told TAMHO that if the application is approved as drafted, it will result in  more funding for the TennCare Program.  TAMHO will continue to advocate for individuals with mental illness and substance use disorders and promote the  advancement of effective services. We will continue to monitor the block grant process to ensure that this vulnerable  population is protected.  The limitation on prescription medicines in the draft application does cause us some concern. Individuals with mental  illness and substance use disorders often require the use of several different medications before ideal outcomes are  realized. If only one medication type is included in the pharmacy formulary, we recommend that there be a simple and  quick process where a physician can request approval for an alternate medication.  Because there are areas of the application that lack detail, we recommend another public comment period once  negotiations with CMS are complete. This is the only way the public will be able to comment on the actual proposed  waiver that should include important details that are not currently available.  Although TennCare leadership has told TAMHO it is their intention, TAMHO recommends that a block grant approval  include a reference that any shared or program savings be designated for TennCare service enhancements.             42 Rutledge Street Nashville, TN 37210‐2043 www.tamho.org (615) 244‐2220 (800) 568‐2642 toll free in TN Fax: (615) 254‐8331 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Emmett Ruff Friday, October 18, 2019 12:36 PM PUBLICE NOTICE TENNCARE Joe Weissfeld; Eliot Fishman; Jane Sheehan [EXTERNAL] Comments on TennCare Amendment 42 FUSA State Comment Letter on TN Block Grant Waiver Amendment.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good afternoon,    Attached are Families USA’s comments on the state’s proposed “Amendment 42” to the TennCare 1115 demonstration.   Please let us know if you have questions related to these comments.    Thank you,      Emmett Ruff Policy Analyst 202-626-0645 ERuff@familiesusa.org    The link ed image cannot be d isplay ed. The file may hav e been mov ed, ren amed, or deleted. Verify that the link poin ts to the correct file and location.   The voice for health care consumers. Join us January 23‐25 for the 25th annual Health Action Conference! #HA2020 #HA25  Facebook     Twitter     LinkedIn   1 October 18, 2019 Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243. Dear Mr. Roberts: Families USA appreciates the opportunity to provide comments on Tennessee’s application for “Amendment 42” of the TennCare II Section 1115 Demonstration Waiver. Families USA is a national health care advocacy organization that supports policies and programs at the state and federal levels to expand access to high quality, affordable health care, with a particular focus on policies that affect lower-income individuals. Multiple elements of this proposed amendment are both legally problematic and poor policy choices for the state. The provisions of this proposal that fail to meet federal requirements and would harm TennCare beneficiaries are discussed in greater detail below. Comments on Specific Provisions in the Amendment Request 1. The Block Grant Puts Families at Risk Families USA is seriously concerned with Tennessee’s proposal to end the 50-plus year federal guarantee of matching each states’ actual Medicaid spending, passing risk and costs onto the state government, taxpayers, and TennCare beneficiaries. A basic concept of the Medicaid program is that it provides federal funds that match a state’s needs and spending. The federal matching structure protects children, pregnant women, seniors, people with disabilities, and working families who rely on Medicaid from being caught in the middle of political, public health, or financial showdowns. Tennessee’s proposed block grant caps the amount of federal funds available for four categories of beneficiaries: children, adults, elderly people, and disabled people, affecting nearly all of the 1.4 million TennCare enrollees. The state’s proposal forgoes the protections of a federal matching structure in favor of a defined federal contribution or “block grant amount” that places the state in the position of having to pay any Medicaid expenditures above the cap with state-only funds. If the state exceeds this cap, it is forced to decide between cutting benefits and coverage or raising taxes to cover the additional cost. The state’s proposed “shared savings mechanism” component of the block grant further incentivizes the state to cut beneficiaries’ benefits and coverage. As described in greater detail below, this financial gimmick would award half of all unspent federal dollars below the capped block grant amount to the state. The state is requesting new “flexibilities” to cut enrollment, services, and benefits in order to reduce spending below the capped block grant amount and generate savings. The clear loser here is TennCare beneficiaries. FamiliesUSA.org 1225 New York Avenue, NW, Suite 800 Washington, DC 20005 main 202-628-3030 / fax 202-347-2417 This proposal puts the health and wellness of Tennesseans in jeopardy, is contrary to federal law, and is not in the state’s best interest. The state should not move forward with its request for federal approval. Per Capita Adjustment Does Not Protect Against Financial and Public Health Vulnerabilities Unlike a traditional block grant, Tennessee’s proposal includes a one-way “per capita adjustment” for changes in enrollment levels. This provision would increase the block grant amount if enrollment exceeds the 3-year average, but would not reduce funds if enrollment decreases. In conjunction with the “shared savings mechanism,” this structure presents the state with a perverse incentive to hold down or reduce enrollment levels in order to keep spending below the capped block grant amount and generate shared savings. The result will likely be a “fox guarding the henhouse” scenario, in which the state uses its well-established pattern of paperwork barriers to cut enrollment and generate savings. Tennessee has a history of non-compliance with Medicaid requirements that resulted in over 150,000 people losing coverage in 2018.1 The one-way per capita adjustment does attempt to address upward fluctuations in enrollment levels, but it insufficiently protects the state from variabilities in the health care system, such as cost increases, workforce changes, or public health crises. Right now, federal support automatically changes to match a state’s spending and needs. Federal support increases if a state’s per capita costs go up, like with an opioid epidemic, natural disaster, or in the event a state decides to cover new medical treatments for its residents. In contrast, Tennessee will face an awful choice in the event of health care cost trends that exceed their proposed inflation rate or a public health crisis under this proposal. This problem is likely to get worse once an inflation rate is negotiated with CMS, given the Trump administration’s clearly stated goal of using block grants to drastically cut federal Medicaid spending. This scenario is not theoretical. Puerto Rico’s experience with capped Medicaid funds shows that it is a dangerous proposition for Medicaid beneficiaries. Hurricanes Maria and Irma showcased the harms of a block grant. But it is not just natural disasters. The block grant approach has disadvantaged Puerto Rico and forced financial hardship as they address issues such as workforce shortages, escalating costs, aging populations, and public health crises. Given Tennessee’s intent to relinquish federal financial support that protects against these types of fluctuations in the health care system, the state should acknowledge this vulnerability and explain how they would address it. Before submitting this proposal to CMS, the state should conduct the following analyses/plans and make them available for public comment:    A comprehensive cost-benefit analysis of the proposal; A plan that demonstrates how the state would address common scenarios to which it would be vulnerable, such as a public health crisis that increases utilization of benefits/services or an unexpected increases in health care costs; and A detailed plan outlining the state’s approach to maintaining services, benefits, and enrollment. 2. The Proposal is Full of Financial Gimmicks and Perverse Incentives 1 https://familiesusa.org/wp-content/uploads/2019/09/Return_of_Churn_Analysis.pdf This proposal creates major new risks for state taxpayers, federal taxpayers, and TennCare beneficiaries. In an attempt to build in financial protections for the state, the proposal includes a number of gimmicks and perverse incentives that fail to advance the objectives of the Medicaid program. Shared Savings Mechanism Offers Impermissible Federal Funding Without a State Match If Tennessee can reduce Medicaid spending dramatically under a block grant using its new “flexibilities” to make cuts, the state’s proposed “shared savings mechanism” would award half of the federal dollars saved to the state, which would essentially be used for state budget relief (described in more detail in the next section). The federal funds awarded to the state as part of the shared savings arrangement can be considered an unmatched bonus payment. Indeed, CMS is awarding these funds in response to limited state spending that is already matched at the regular rate. Put simply, the federal government is awarding the state 50% of its own federal savings, while the state retains its own state savings. This amounts to 100% federal medical assistance, which violates the non-waivable section 1905(b)(1) of the Social Security Act, which states that “the Federal medical assistance percentage shall in no case be less than 50 per centum or more than 83 per centum.” This provision is inconsistent with federal law and should be removed from the application along with the many other provisions that are contingent on approval of this provision. Uses “Costs Not Otherwise Matchable (CNOMs)” to Fill Budget Gaps As part of the “shared savings mechanism” described above, the state is proposing that it be awarded half of the federal dollars saved for state budget relief. On paper, Tennessee proposes to use those savings to re-invest into health. In practice, states like Vermont have used this type of authority to cover existing spending not typically covered by Medicaid: that is, to save money in other parts of the state budget. Notably, the state does not provide details about these proposed investments. The fact that Tennessee is simply asking for a blank check with no strings attached from the federal government is problematic on its own terms. In this context, where the state has strong incentivizes to cut benefits and/or enrollment, the proposed “shared savings mechanism” makes an already bad problem worse by intensifying the fiscal incentive to cut insurance eligibility and benefits. Expends State Resources to Administer the New Approach Tennessee is volunteering to change the way it administers Medicaid funds, which will require new expertise and resources. The state will need to manage its budget neutrality costs on an annual basis instead of a five-year basis. Shortening the budget time horizon exposes the state to annual costs that will likely not be recouped over a five-year period since it is unlikely that CMS will approve the “shared savings” approach described above. The state also is proposing to waive its ability to increase the per member per month spending and receive a federal match. These changes will not manage themselves. New efforts will require additional resources from state officials. These costs should be transparent, there should be a plan to evaluate these costs, and these costs should be included in the budget neutrality analysis. 3. The Proposal Incentivizes and Streamlines the Process for Tennessee to Cut Benefits and Enrollment The budget gimmicks described above give the state incentives to cut benefits and enrollment. By itself, these are worrisome changes. However, the state goes further in requesting unprecedented “flexibilities” to limit benefits and impact enrollment without a transparent oversight process. The combination of financial incentives and limited oversight represents a major threat to beneficiaries in the state. Allows Modification of Core Components of the Medicaid Program without Transparency or Oversight The state proposes “flexibilities” to alter several elements of its Medicaid program “without seeking additional CMS approvals via State Plan amendments or demonstration amendments.” Essentially, the state is requesting a blank check from CMS to make additional unspecified changes to its Medicaid program without complying with processes for federal oversight. Allowing the state to limit benefits without a transparent oversight process is dangerous. If the state exceeds their allotted block grant budget, this provision gives the state an “out” to cut or limit benefits. Given that CMS will continue to cover a majority of the cost of the state’s Medicaid program, CMS is extremely unlikely to relinquish its oversight of the state’s program. We recommend that Tennessee remove this provision from its application. Eliminates Oversight into the Managed Care Program The state is requesting a blanket waiver of federal requirements related to Medicaid managed care in 42 CFR Part 438 to restructure its managed care delivery system. A waiver of all Medicaid managed care requirements in 42 CFR Part 438 would give the state authority to waive requirements designed to protect beneficiaries’ and their providers, such as prohibition of provider discrimination, network adequacy standards, beneficiary support systems, grievance and appeals processes, program integrity safeguards, sanctions, and parity in mental health and substance use disorder benefits. As stated above, the “shared savings mechanism” incentivizes the state to generate savings at the expense of beneficiaries. A blanket waiver of Medicaid managed care requirements would allow the state to generate savings by cutting the infrastructure that protects managed care enrollees and by compromising their access to care. The state provides examples of “unnecessary” federal requirements that could be waived with approval of this amendment, but does not explicitly list the specific requirements it would waive if the proposed amendment is approved by CMS. Because the state does not name the specific waived requirements, the impact on beneficiaries, providers, and managed care entities remains unknown. For this reason, we request that the state specify which Medicaid managed care requirements it is requesting flexibility to waive and how these proposed waivers would impact beneficiaries and their providers. We also recommend that Tennessee remove this provision from its application. Allows Adding or Eliminating Optional State Plan Benefits without Oversight The state is requesting a waiver to cut or limit optional state plan benefits and place additional limits on mandatory benefits without federal oversight or approval. Waiving federal protections and unilaterally limiting benefits without a transparent oversight process is worrisome, especially given the state’s proposal to share federal savings as part of its block grant. Under a “shared savings mechanism” the state is incentivized to generate savings by spending less than the allotted block grant amount. This “shared savings mechanism” incentivizes the state to cut benefits to spend less per beneficiary and thereby generate savings. At the same time, if the state exceeds the block grant amount, this provision offers the state with a pathway to cut or limit benefits and avoid assuming additional financial risk. The state does not specify which state plan benefits would be added or eliminated if this waiver amendment is approved. As such, the impact on beneficiaries as well as the implications for federal and state funding remain unknown. At a minimum, we request that the state provide additional detail on how its proposed waiver of 1902(a) would modify the “amount, duration, and scope” of specific optional and mandatory state plan benefits and how this waiver would affect beneficiaries as well as state and federal expenditures. However, we recommend that the state withdraw its request for a waiver to cut state benefits without federal approval. Permits Targeting Benefits for Certain Populations, but Doesn’t Take Advantage of Existing Flexibilities Tennessee proposes to waive 1902(a)(10)(B) comparability standards to provide targeted benefits to certain TennCare populations. The state justifies its request with an example that the state cannot provide targeted and limited dental benefit to pregnant women “unless they have sufficient funds to provide dental services to all adults” and describes the 1115 waiver application process as “unnecessarily long and onerous.” However, the state does not need a block grant or an 1115 waiver to provide a dental benefit to pregnant beneficiaries. Instead, the state can simply submit a State Plan Amendment (SPA), as Virginia did in 2015.2 We strongly encourage the state to pursue a SPA to provide dental benefits to pregnant women. Given that Tennessee is one of the few states that does not cover dental services for all adults in its Medicaid program, we also encourage the state to expand its Medicaid dental services benefit to cover adults. Additionally, the state uses “providing a limited dental benefit to pregnant women” as an example of a targeted benefit for which it is requesting a waiver of comparability. However, the state does not actually propose to provide any specific benefits, nor does it name certain populations who would receive these benefits. Finally, a waiver of comparability to provide targeted benefits can potentially address or exacerbate health inequities among TennCare beneficiaries. Targeted benefits could focus on vulnerable populations that experience specific health inequities and require certain services, or targeted benefits could exclude certain populations that need those services the most. Additionally, since the state is proposed to “use block grant funds on public health initiatives that are not specifically targeted at the TennCare population,” this could create a scenario in which TennCare beneficiaries receive limited benefits, while other populations (such as higher-income Tennesseans who earn too much to qualify for TennCare) benefit from the state’s flexible use of federal funds. But again, since the state has not actually proposed a targeted benefits package or eligible populations, the effect of such a waiver remains unknown. At a minimum, we request that the state provide additional detail on what specific benefits and populations would be subject to the proposed waiver of comparability. Overall, we recommend that the state withdraw this request completely. Allows Enrollment and Delivery Systems Changes without Oversight 2 https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/VA/VA-15001.pdf The state is requesting flexibility to “modify enrollment processes, service delivery systems, and comparable program elements” without submitting additional waiver applications or state plan amendments to CMS for approval. This flexibility also represents a major threat to beneficiaries in the state given the state’s proposal to share federal savings as part of its block grant. As stated above, the “shared savings mechanism” incentivizes the state to generate savings by spending less than the allotted block grant amount, which is based on projected enrollment. This incentivizes the state to reduce enrollment so that spending falls below the block grant amount, thereby generating savings. Over the years, Tennessee’s enrollment processes have failed to comply with federal regulations, which has resulted in massive drops in enrollment. Between 2013 and 2016, the state failed to update its eligibility system to comply with federal regulations, which caused thousands of Tennesseans to lose their Medicaid coverage, despite being eligible.3 From 2016 until just recently, redeterminations could not be processed online, and the state attempted to mail and process lengthy paper renewal packets, which created paperwork barriers to enrollment for parents and their children.4 Also contrary to federal law, the state failed to screen children for eligibility under other Medicaid categories before disenrolling them, resulting in children losing coverage despite qualifying under another category.5 According to the Tennessee Justice Center’s review of state records, paperwork-driven terminations ended health coverage for 220,000 children between 2016 and 2018.6 Based on state Medicaid enrollment data, nearly 150,000 fewer beneficiaries were enrolled in Medicaid between December 2017 and December 2018.7 New flexibilities to modify enrollment processes without federal approval will allow the state to continue its well-established pattern of cutting enrollment to generate savings. The state notes that it contracts with multiple managed care organizations and health plans for the delivery of services, but provides no additional detail regarding what specific modifications would be made if granted these flexibilities. For this reason, we request that the state provide additional detail regarding how it would modify specific enrollment processes and “comparable program elements” and how these modifications impact enrollment. In any event, flexibility to make cuts does not promote the objectives of the Medicaid program. We recommend that the state withdraw its request to modify enrollment processes and “comparable program elements” without federal approval. Changes Requirements for Hospitals to Receive Uncompensated Care Funds The state requests flexibility to “modify the participation criteria and distribution methodology associated with the state’s two uncompensated care funds” without submitting additional waiver applications or state plan amendments to CMS for approval. Once again, the state provides an example of a possible modification: “condition a hospital’s participation in one or both uncompensated care funds on its participation in outcomes- or quality-based payment initiatives,” which could ultimately improve quality of care and outcomes for beneficiaries. However, the state does not commit to any 3 https://familiesusa.org/sites/default/files/product_documents/Return_of_Churn_Analysis.pdf https://familiesusa.org/sites/default/files/product_documents/COV_Child%20Health%20Emergency_Report%20P art%20I.pdf 5 https://ccf.georgetown.edu/2019/04/08/whos-minding-the-store-for-tennessees-children-who-rely-onmedicaid-and-chip/ 6 https://www.tnjustice.org/wp-content/uploads/2019/07/How-Tennessee-Became-an-Outlier-in-the-RisingNumber-of-Uninsured-Children-and-What-Must-Happen-to-Reverse-the-Trend-1.pdf 7 https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/monthlyreports/index.html 4 specific modifications regarding how hospitals receive payments from uncompensated care funds. We recommend that Tennessee provide additional details on this provision. Includes Extra Statutory Provision on Fraud Tied to Eligibility Loss The state’s new waiver proposal includes loss of eligibility for fraud. The state proposes to develop policies, but does not include those details in the proposal. It is concerning that the state is asking for a blank check to lock individuals out of the Medicaid program. There is not statutory basis for using Medicaid eligibility as a penalty for fraud 4. Other Concerning Provisions Offers Unprecedented Permanent Approval of TennCare 1115 Waiver The state’s amendment application includes a proposal for “CMS to approve of the TennCare 1115 demonstration waiver on a permanent basis and only require amendments to the waiver to go through the approval process.” At the same time, as indicated above, the state is requesting to make additional changes to its waiver without submitting an amendment to CMS for approval. In combination, the state is effectively eliminating federal oversight of its waiver permanently, despite proposing a new funding structure that includes enhanced federal financial participation. To date, no Section 1115 waiver has received permanently approval as it runs counter to the very nature of the concept of a demonstration. On November 6, 2017, CMS released an informational bulletin8 indicating that it “may approve the extension of routine, successful, non-complex section 1115(a) waiver and expenditure authorities in a state for a period up to 10 years.” Given this proposal’s variety of new requests, its lack of success in terms of complying with federal regulations, its intention to make additional changes without federal oversight, the complexity and novelty of its proposed block grant funding structure, and the fact that the state’s proposal is an amendment and not an extension, the waiver can hardly be considered routine, successful, or non-complex. Therefore, a ten-year approval is highly unlikely. A permanent approval would be unprecedented and irresponsible. We recommend that Tennessee remove this provision from the application. Attempts to Adopt a Closed Drug Formulary The state is proposing to adopt a closed formulary to limit the number of drugs covered by Medicaid, particularly new drugs and drugs without “clinical benefit.” The state proposes to negotiate with manufacturers to provide them with an “essentially guaranteed volume” of drugs in exchange for a larger drug rebate. This request will limit beneficiaries’ access to beneficial drugs, is unlikely to generate a costs savings, and is unlikely to receive CMS approval. The state is requesting to waive 1902(a)(54) insofar as it incorporates section 1927. But section 1115 statute does not reference section 1927 (outpatient drugs), a statutory limitation that Tennessee’s proposal simply ignores. The existence of 1902(a)(54) does not render 1927 non-existent or subject to 1115 waiver, which means section 1115 authority cannot be used to waive section 1927. 8 https://www.medicaid.gov/federal-policy-guidance/downloads/cib110617.pdf Even on its own legally dubious terms, Tennessee’s proposal does not make sense from a policy standpoint. Massachusetts requested a similar 1115 waiver amendment in 2018 and was denied.9 In its decision not approve Massachusetts’ request, CMS noted that for a state to adopt a closed Medicaid drug formulary, it would have to first drop optional State plan drug coverage under section 1902(a)(54) of the Social Security Act and “forgo all manufacturer rebates available under the federal Medicaid Drug Rebate Program.” Forgoing manufacturer rebates eliminates the possibility of the state controlling drug costs and generating savings by negotiating with manufacturers. It is unlikely that any significant cost savings would result from adopting a closed formulary in Medicaid. For instance, Medicare Part D prescription drug plans can, with the exception of certain protected classes of drugs, implement closed formularies, but this has resulted in rebates that are much smaller than those in the Medicaid Drug Rebate Program. Additionally, though states cannot currently implement a closed formulary, they can use similar tactics to negotiate directly with manufacturers for supplemental rebates. Yet, such tactics have resulted in only small rebates on top of the required rebates.10 This means that if this waiver were to result in significant savings, it could only do so by overly restricting access to needed and possibly even lifesaving medications for Medicaid beneficiaries. The state proposes to implement a closed formulary to exclude new drugs that “have not yet demonstrated actual clinical benefit” from coverage new drugs with “limited or inadequate clinical efficacy.” Although it is important that pharmaceutical manufacturers are incentivized to produce new and innovative drugs that meet critical health and public health needs, there is often therapeutic value in having multiple drugs for a given condition. Two drugs may have essentially the same effectiveness at a population level, but individual consumers may need or prefer to take one medication over another due to side effects, interactions with other medications or health conditions, or ease of adherence. Additionally, much of the evidence used to demonstrate a drug’s clinical benefit is based on studies with overwhelmingly white participants, and there may be important differences in drug efficacy for people of color.11 Therefore, we recommend that Tennessee remove this provision, which does not promote Medicaid objectives, from its proposed application. Removes Beneficiary Notification and Communication Requirements The state is requesting assurances from CMS that there will be no negative enforcement action taken against the state should it stop mailing minimum essential coverage notices to beneficiaries. The state claims that, because the individual mandate is effectively no longer enforced, these minimum essential coverage notices “no longer serve any useful purpose.” However, minimum essential coverage notices still serve a useful purpose by informing beneficiaries of whether, depending on the type of Medicaid coverage they receive, they are eligible for premium tax credits or other savings to enroll in Marketplace 9 https://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Waivers/1115/downloads/ma/MassHealth/ma-masshealth-demo-amndmnt-appvl-jun-2018.pdf 10 Edwin Park, Center for Children & Families (CCF) of the Georgetown University Health Policy Institute, Trump Administration Medicaid Drug Rebate Proposal Raises Serious Concerns for Beneficiaries, Unlikely to Reduce Costs (Washington, DC: CCF, April 2, 2018), available online at https://ccf.georgetown.edu/2018/04/02/trumpadministration-medicaid-drug-rebate-proposal-raises-serious-concerns-for-beneficiaries-unlikely-to-reduce-costs/. 11 Esteban Burchard, Sam Oh, Marilyn Foreman, and Juan Celedón, “Moving toward True Inclusion of Racial/Ethnic Minorities in Federally Funded Studies. A Key Step for Achieving Respiratory Health Equality in the United States,” American Journal of Respiratory and Critical Care Medicine191, no. 5 (January 2015), available online at https://www.atsjournals.org/doi/abs/10.1164/rccm.201410-1944PP?url_ver=Z39.882003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed. insurance plans. For example, medically needy beneficiaries who qualify for coverage after incurring and spending down medical expenses as well as beneficiaries who receive limited benefits may qualify for subsidies to enroll in Marketplace coverage and should be made aware of their coverage options. For this reason, the state should continue to mail minimum essential coverage notices to beneficiaries. We therefore recommend that Tennessee remove this provision from the application. Conclusion Overall, the state’s application lacks a coherent, data supported rationale for its proposal, showing how approval of the proposal will further the objectives of the Medicaid program. It lacks meaningful projections of enrollment losses from the proposal’s major provisions. The legally required 1115 notice and comment period is not meaningful if states do not articulate how their requests are related to Medicaid’s objectives and if the process does not afford full public comment on that rationale. For these reasons and those outlined in this letter, it is not in the state’s best interest to move forward with this request for a new proposed Medicaid section 1115 demonstration waiver. The state’s proposed amendment does not promote the objectives of Medicaid—indeed it poses a grave threat to Medicaid coverage in Tennessee. The proposal would create overwhelming financial incentives for the state to cut TennCare eligibility and benefits. Furthermore, the proposal fails to address significant issues facing the state’s program and misses an opportunity to make much needed improvements. This proposal:  Does Not Expand Coverage: Tennessee is one of fourteen states that has not expanded Medicaid. The state could achieve a 90% federal match for 244,000 people rather than basing a block grant on their current 65.21% federal match rate. Instead of providing cost-effective coverage to more Tennesseans in need, the state’s proposal incentivizes cuts to enrollment, benefits, or access for its current population.  Does Not Address Tennessee’s History of Poor Program Management: As discussed in greater detail below, Tennessee has history of aggressive policies that led to thousands of eligible beneficiaries losing their Medicaid coverage, including a large proportion of children.12 These massive declines in coverage can be attributed to poor program management. Removing or limiting federal oversight into the Tennessee Medicaid program could allow this poor program management to continue, with disastrous consequences for beneficiaries.  Waives parts of Medicaid Law not Subject to Waiver: Section 1115 waivers gives states broad authority to waive provisions. However, this proposal makes at least two requests that fall outside of the authority of the 1115 waiver authority. First, the language defining the matching rate appears in a section of the Social Security Act—section 1903—that the Secretary does not have the authority to waive. Second, in no way does the block grant proposal “assist in promoting the objectives” of the Medicaid program. Therefore, the Secretary cannot legally approve this request. Instead of moving forward with this legally questionable waiver request that would result in devastating coverage and benefit losses, the state should focus on improving its Medicaid program by pursuing a 12 https://familiesusa.org/wp-content/uploads/2019/09/Return_of_Churn_Analysis.pdf Medicaid expansion, improving its enrollment practices, and addressing health inequities and social determinants of health. Thank you for your consideration of these comments. If you have any questions, please contact Emmett Ruff at ERuff@familiesusa.org or Joe Weissfeld at JWeissfeld@familiesusa.org or call 202-628-3030. Respectfully submitted, Joe Weissfeld, MPP Director of Medicaid Initiatives at Families USA Emmett Ruff Policy Analyst at Families USA Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Regina Reed Friday, October 18, 2019 12:29 PM PUBLICE NOTICE TENNCARE Barbara DiPietro; Bobby Watts [EXTERNAL] NHCHC's Comments on TennCare II Demonstration, Project No. 11-W-00151/4, Amendment 42 NHCHC comments on TennCare Amendment 42 Block Grant.pdf; Attachment _Medicaid and Health Care for the Homeless The Dangers of Block Grants or Per Capita Caps.pdf; ATTACH~2.PDF   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Office of Director Division of TennCare,    Please accept the comments and affiliated documents attached to this email on TennCare II Demonstration’s  Amendment 42. The text of the comments are also copied below my signature.     To respond you may reply to this email or contact Barbara DiPietro, PhD, Senior Director of Policy, at 443‐703‐1346 or at  bdipietro@nhchc.org (CCed).    Thank you,    Regina Reed, MPH  Health Policy Organizer  National Health Care for the Homeless Council  443‐703‐1337     pronouns: she/her/hers    October 18, 2019 Submitted via email to public.notice.tenncare@tn.gov Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243. RE: TennCare II Demonstration, Project No. 11-W-00151/4, Amendment 42 Dear Mr. Roberts, Thank you for the opportunity to comment on the TennCare II Demonstration’s Amendment 42, hereby referred to as “Amendment 42.” If implemented, Amendment 42 would restructure the TennCare Medicaid program’s funding to a block grant. The National Health Care for the Homeless Council is a membership organization representing federally funded health centers and other organizations providing health services to people experiencing homelessness. In 2018, seven federally funded Health Care for the Homeless (HCH) programs in Tennessee provided care to nearly 19,000 patients experiencing homelessness. Of these 1 patients, approximately 60% were uninsured and 20% are enrolled in Medicaid. As a network of providers caring for very vulnerable people, we are extremely concerned about the impact of Amendment 42 on our patients’ health and livelihood and we stand in adamant opposition to block grants and spending caps in the Medicaid program. We hope that the perspectives provided in this letter (along with the supplementary information linked at the bottom) illustrate why Amendment 42 is so harmful, and specifically how it undermines national efforts to improve health outcomes. In order to improve outcomes and access to care, the state of Tennessee should expand coverage, not reduce it through cost-cutting measures such as a block grant. We acknowledge that Tennessee is not pursuing a traditional block grant, per se, and is attempting to mitigate some of the negative effects of a traditional block grant by requiring the federal government to increase the amount of money offered if enrollment grows and sharing cost savings with the federal government. While we appreciate the intent to mitigate the worst effects of a traditional block grant, we must emphasize that these provisions do not ameliorate the dangers of a block grant and Amendment 42 continues to pose significant harm to the health of Tennesseans[i]. High rates of uninsured patients place a financial burden on safety net programs to cover costs, further stressing an already under-resourced system. Without insurance to cover needed services, it is difficult to deliver preventative medicine and keep patients under regular care. Untreated chronic conditions, mental health, addiction, and other health issues can then worsen and contribute to an overall downward spiral, often leaving patients with no choice but to end up seeking care in emergency rooms, hospitals, and other higher-cost venues. While many of our patients are already uninsured, Amendment 42 would give the state more financial incentive to limit the “amount, duration, and scope” of core benefits for those who do have coverage, thereby incentivizing the state to limit access to health services.[ii] For patients experiencing homelessness, having access to Medicaid’s comprehensive set of services is the key to improving and maintaining health. Lack of insurance coverage is a primary cause of poor health outcomes and poor health outcomes are a driver of homelessness. In addition, homelessness causes new health conditions and worsens existing ones, contributing to early mortality for this population. To focus on cost-cutting within the Medicaid program while our patients suffer irreparable damage due to a lack of Medicaid coverage is not in the best interests of Tennesseans, and may have deadly consequences for the most vulnerable people. We hope that the state of Tennessee will invest in health care by expanding Medicaid to all low-income Tennesseans and forgo the dangerous and ill-advised approach of Amendment 42. Attached to the electronic submission are two resources that further detail the impact of Medicaid restrictions and expansions on homelessness and health care. If you would like to discuss these comments further, please contact Barbara DiPietro, PhD, Senior Director of Policy, at 443-703-1346 or at bdipietro@nhchc.org Sincerely, G. Robert Watts, MPH, MS, CPH Chief Executive Officer ATTACHMENTS: A. National Health Care for the Homeless Council, Medicaid and Health Care for the Homeless: The Dangers of Block Grants or Per Capita Caps and Guiding Principles for Reform, January 2017, 2 accessed at https://nhchc.org/wp-content/uploads/2019/08/block-grants-caps-and-principlesfor-reform.pdf B. Kaiser Family Foundation, Early Impacts of the Medicaid Expansion for the Homeless Population, November 2014, accessed at https://www.kff.org/uninsured/issue-brief/early-impacts-of-themedicaid-expansion-for-the-homeless-population/          Health Care for the Homeless is building a future without homelessness. Support our work at www.hchmd.org. THE INFORMATION CONTAINED IN THIS MESSAGE IS LEGALLY PRIVILEGED AND CONFIDENTIAL INFORMATION INTENDED FOR THE USE OF THE ADDRESSEE LISTED ABOVE. This  record has been disclosed in accordance with Subtitle 3 of Title 4 of the Health‐General Article of the Annotated Code of Maryland. Further disclosure of medical information  contained herein is prohibited. If you are neither the intended recipient nor the individual responsible for delivering this message to the intended recipient, you are hereby notified  that any disclosure of patient information is strictly prohibited. If you have received this email in error, immediately notify us by telephone or return email.                                                               [i] Rachel Sachs, Nicole Huberfeld, “The Problematic Law and Policy of Medicaid Block Grants,” Health Affairs Blog, July 2019, accessed at https://www.healthaffairs.org/do/10.1377/hblog20190722.62519 /full/ Hannah Katch, Judith Solomon, Aviva Aron-Dine, “Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries,” Center on Budget and Policy Priorities, September 2019, accessed at https://www.cbpp.org/research/health/tennessee-block-grant-proposal-threatens-care-for-med icaid-beneficiaries [ii] 3 October 18, 2019 Submitted via email to public.notice.tenncare@tn.gov Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243. RE: TennCare II Demonstration, Project No. 11-W-00151/4, Amendment 42 Dear Mr. Roberts, Thank you for the opportunity to comment on the TennCare II Demonstration’s Amendment 42, hereby referred to as “Amendment 42.” If implemented, Amendment 42 would restructure the TennCare Medicaid program’s funding to a block grant. The National Health Care for the Homeless Council is a membership organization representing federally funded health centers and other organizations providing health services to people experiencing homelessness. In 2018, seven federally funded Health Care for the Homeless (HCH) programs in Tennessee provided care to nearly 19,000 patients experiencing homelessness. Of these patients, approximately 60% were uninsured and 20% are enrolled in Medicaid. As a network of providers caring for very vulnerable people, we are extremely concerned about the impact of Amendment 42 on our patients’ health and livelihood and we stand in adamant opposition to block grants and spending caps in the Medicaid program. We hope that the perspectives provided in this letter (along with the supplementary information linked at the bottom) illustrate why Amendment 42 is so harmful, and specifically how it undermines national efforts to improve health outcomes. In order to improve outcomes and access to care, the state of Tennessee should expand coverage, not reduce it through cost-cutting measures such as a block grant. We acknowledge that Tennessee is not pursuing a traditional block grant, per se, and is attempting to mitigate some of the negative effects of a traditional block grant by requiring the federal government to increase the amount of money offered if enrollment grows and sharing cost savings with the federal government. While we appreciate the intent to mitigate the worst effects of a traditional block grant, we must emphasize that these provisions do not ameliorate the dangers of a block grant and Amendment 42 continues to pose significant harm to the health of Tennesseans1. High rates of uninsured patients place a financial burden on safety net programs to cover costs, further stressing an already under-resourced system. Without insurance to cover needed services, it is difficult to deliver preventative medicine and keep patients under regular care. Untreated chronic conditions, mental health, addiction, and other health issues can then worsen and contribute to an overall downward spiral, often leaving patients with no choice but to end up seeking care in National Health Care for the Homeless Council P.O. Box 60427 Nashville, TN 37206-0427 (615) 226-2292 www.nhchc.org Page 2 emergency rooms, hospitals, and other higher-cost venues. While many of our patients are already uninsured, Amendment 42 would give the state more financial incentive to limit the “amount, duration, and scope” of core benefits for those who do have coverage, thereby incentivizing the state to limit access to health services.2 For patients experiencing homelessness, having access to Medicaid’s comprehensive set of services is the key to improving and maintaining health. Lack of insurance coverage is a primary cause of poor health outcomes and poor health outcomes are a driver of homelessness. In addition, homelessness causes new health conditions and worsens existing ones, contributing to early mortality for this population. To focus on cost-cutting within the Medicaid program while our patients suffer irreparable damage due to a lack of Medicaid coverage is not in the best interests of Tennesseans, and may have deadly consequences for the most vulnerable people. We hope that the state of Tennessee will invest in health care by expanding Medicaid to all low-income Tennesseans and forgo the dangerous and ill-advised approach of Amendment 42. Attached to the electronic submission are two resources that further detail the impact of Medicaid restrictions and expansions on homelessness and health care. If you would like to discuss these comments further, please contact Barbara DiPietro, PhD, Senior Director of Policy, at 443-703-1346 or at bdipietro@nhchc.org Sincerely, G. Robert Watts, MPH, MS, CPH Chief Executive Officer ATTACHMENTS: A. National Health Care for the Homeless Council, Medicaid and Health Care for the Homeless: The Dangers of Block Grants or Per Capita Caps and Guiding Principles for Reform, January 2017, accessed at https://nhchc.org/wp-content/uploads/2019/08/block-grants-caps-and-principlesfor-reform.pdf B. Kaiser Family Foundation, Early Impacts of the Medicaid Expansion for the Homeless Population, November 2014, accessed at https://www.kff.org/uninsured/issue-brief/early-impacts-of-themedicaid-expansion-for-the-homeless-population/ Rachel Sachs, Nicole Huberfeld, “The Problematic Law and Policy of Medicaid Block Grants,” Health Affairs Blog, July 2019, accessed at https://www.healthaffairs.org/do/10.1377/hblog20190722.62519 /full/ 1 Hannah Katch, Judith Solomon, Aviva Aron-Dine, “Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries,” Center on Budget and Policy Priorities, September 2019, accessed at https://www.cbpp.org/research/health/tennessee-block-grant-proposal-threatens-care-for-med icaid-beneficiaries 2 National Health Care for the Homeless Council P.O. Box 60427 Nashville, TN 37206-0427 (615) 226-2292 www.nhchc.org Medicaid and Health Care for the Homeless: The Dangers of Block Grants or Per Capita Caps and Guiding Principles for Reform Medicaid expansion directly helped improve access to health coverage for homeless populations in states that expanded. In the 30 states that expanded Medicaid in 2015, we have seen the uninsured rate fall significantly in just two years—from 59% in 2013 to 37% in 2015. HCH projects in some expansion states, like Arizona, Kentucky, Maryland and Michigan, have been able to reduce the level of uninsured among their patients by well over half. Unfortunately, in non-expansion states, very little has changed. By the end of 2015, 69% of patients at HCH projects in these 21 states lacked health insurance (down from 74% in 2013). The disparity in access to care based on Medicaid eligibility has direct implications for patient health status, overall public costs, the stability of safety net providers, and state-level health reform efforts. People who are homeless have significant health care needs—to include addiction and mental health conditions—and have benefited from the Medicaid expansion. Poor health and limited access to care is a primary cause of homelessness. Those without homes often suffer from high rates of behavioral health conditions such as opioid addiction, depression, and anxiety; chronic disease such as diabetes, asthma, and hypertension; acute injuries such as frostbite and wounds; and communicable illness, such as Hepatitis C and tuberculosis. As outpatient primary care and behavioral health providers, there’s a limit to what we can do in a health center—having access to the full system of care allows us to connect patients to the broader specialty services they need to get better and focus on regaining housing and employment. As many states continue to battle a growing opioid and mental health epidemic, Medicaid is the primary funder of these critical services—without it, there is little to no access to treatment or recovery. As a result, people with behavioral health conditions are overwhelmingly incarcerated in jails and prisons—often at 100% state and local expense. A stable health insurance benefit such as Medicaid helps prevent this downward spiral that has extensive human and economic consequences. Medicaid helps lower costs and end homelessness. Because of high health needs and lack of housing, people who are homeless tend to use hospitals and emergency departments at high rates, with longer lengths of stays, higher risks for readmission, and poorer outcomes. Medicaid expansion has allowed states and local jurisdictions to better connect people to outpatient, community-based care and provide better coordination for needed services. A number of states have also used optional flexibilities in Medicaid to fund more support services to allow better transitions to housing for longNational Health Care for the Homeless Council P.O. Box 60427 Nashville, TN 37206-0427 (615) 226-2292 www.nhchc.org term homeless individuals. This has been shown to reduce use of hospitals, emergency departments, jails, prisons, court systems, and first responders with direct savings to local, state and federal expenditures. As our patients get better, they become more stable, use fewer high-cost services, and can return to employment, housing, family stability, and greater overall productivity. Achieving these types of outcomes is much harder under block grants and caps since the funding would be limited to short-term patches rather than longer-term solutions. Community-based providers need Medicaid’s stability and comprehensive care in order to provide high quality, cost-effective care and expand the workforce. Prior to Medicaid expansion, we were only able to secure preventive health screens (like mammograms and colorectal cancer screenings) or specialty care (like cardiology or orthopedics) through ad hoc pro bono arrangements, which were time-consuming to secure and inadequate to meet the vast need we encounter. Now, our providers in expansion states have access to a wide range of prescription drugs, networks of specialists, and a more stable system of care in order to better manage the complex needs of our patients. The financial stability that Medicaid offers allows us to make better use of limited grant dollars to fund additional services like case management, adult dental care, and outreach as well as hire more staff to fulfill our mission. Since 2014, many of our clinics in expansion states have hired more physicians, nurses, care coordinators, outreach workers, case managers, addiction specialists, and mental health providers. These workforce expansions not only provide good local jobs but also help meet community health care needs and have allowed many clinics to expand needed services. Putting Medicaid under artificial limits like a block grant or cap will undercut these workforce expansions and public health goals. Medicaid is a crucial part of state-based health reform and other public health efforts. States have invested heavily in transforming their health care systems, investing millions in new delivery of care models, information sharing systems, and moving to innovative payment mechanisms that recognize social determinants of health. Treatment and recovery services for those with mental health and opioid addiction (as well as a host of other chronic diseases) have featured prominently among these plans, and are connected to state-level goals for improving overall health. Changing Medicaid from a traditional insurance structure to a block grant or capped amount fundamentally compromises the significant amount of work that has already been invested to integrate newly insured individuals into a better health care system, particularly in states that have expanded Medicaid. Block grants and caps stymie flexibility and innovation, and will harm the poorest and most vulnerable. These payment models do not allow for a system of care, but rather a rationed approach that isn’t able to respond to individual or community needs, particularly in a crisis situation. For highcost populations needing a broader and deeper range of care, grants-based annual budgets will again drive the majority of decisions, taking us back to the “penny-wise, pound-foolish” inadequate approaches that have plagued the American health care system for years. This only results in high costs, poor outcomes, and wasted opportunities for better health and more productive lives. The current Medicaid program is exceedingly flexible, and all states are currently using those flexibilities to demonstrate various new approaches to meet needs, such as supportive housing services, medical respite care, care coordination, integrated health, etc. National Health Care for the Homeless Council P.O. Box 60427 Nashville, TN 37206-0427 (615) 226-2292 www.nhchc.org From our 30 years’ experience providing health care to people who are homeless, we have found the following three principles are vital components of any high-quality health care system:  Establish universal eligibility to comprehensive coverage: We advocate for a system that provides health coverage to every American with no restrictions based on income level, employment status, citizenship status, criminal justice involvement, or health status. While a single payer system would be the most efficient and cost-effective model, the expansion of Medicaid under the ACA to people earning at or below 138% of poverty filled extensive coverage gaps (in states that expanded) and should be maintained. Health coverage through any insurer, whether the federal government, employer, or other private insurer, should include the comprehensive set of essential health benefits already established in law but expanded to include adult dental services (this includes community-based and hospital services, behavioral health care, women’s reproductive services, prescription drugs, preventive health screens, and any other service beneficial to the health of the individual).  Eliminate barriers to coverage and care: Entry into coverage should be streamlined, simple to navigate, and continuous—with no premiums, copays or other out-of-pocket costs for those at the lowest income levels, and no lockout periods or discontinued coverage for failure to complete health assessments or similar requirements. Coverage should be affordable for all income levels. Health savings accounts, subsidies, and tax credits, although easier to use for those at higher income levels, serve as a significant barrier to accessing services for very low-income individuals and should never be required for coverage. Likewise, there should be no work, education, or training requirements for participation in health coverage, nor should coverage be limited or capped (via block grants or individual spending caps). Networks of care providers should be adequately available and reimbursed for services.  Recognize social determinants of health: Lack of housing creates and exacerbates health problems and makes engagement in health care more difficult. Effective health care systems align health and housing services—such as supportive housing, medical respite care, case management, and residential treatment—to ensure positive health outcomes and housing stability for high-need populations. We have seen first-hand how the Medicaid program as it currently configured brings states the flexibility they need to tailor programs, and how providers rely on Medicaid to facilitate high-quality care and stabilize the health of very vulnerable people. Block grant and caps only undermine the progress made to connect people to the care they need, and will certainly limit our ability to prevent and end homelessness among the patients we serve. National Health Care for the Homeless Council P.O. Box 60427 Nashville, TN 37206-0427 (615) 226-2292 www.nhchc.org 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Early Impacts of the Medicaid Expansion for the Homeless Population Barbara DiPietro, Samantha Artiga (https://www.kff.org/person/samantha-artiga/) (https://twitter.com/SArtiga2), and Alexandra Gates (https://www.kff.org/person/alexandra-gates/) Published: Nov 13, 2014 Executive Summary The A ordable Care Act (ACA) Medicaid expansion o ers a signi cant opportunity to increase coverage and improve access to care for individuals experiencing homelessness, who historically have had high uninsured rates and often have multiple, complex physical and mental health needs. This analysis provides an early look at the impact of the expansion for homeless providers and the patients they serve, building on an earlier brief (https://www.k .org/health-reform/report/medicaid-coverage-and-care-for-the-homeless/) examining the potential role of Medicaid expansion for this population. It is based on focus groups conducted with administrators, providers, and enrollment workers at four sites serving homeless individuals in states that have expanded Medicaid (Albuquerque, NM; Baltimore, MD; Chicago, IL; and Portland, OR) and one site in a state that has not expanded (Jacksonville, FL), as well as administrative data collected from the sites.  It nds: The Medicaid expansion has led to signi cant increases in coverage that are contributing to improved access to care and broader bene ts for homeless individuals. Participants and data from the study sites indicate that the Medicaid expansion has led to signi cant gains in coverage among the individuals they serve (Figure 1). Providers reported that these coverage gains have enabled patients to access many services that they could not obtain while uninsured, including some life-saving or life-changing surgeries or treatments. Participants also identi ed other broader bene ts for homeless individuals stemming from Medicaid coverage gains. For example, providers noted improvements in individuals’ ability to work and maintain stable housing due to better management of health conditions. In addition, participants said individuals have reduced nancial stress and improved access to other services and programs, including disability bene ts. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 1/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Figure 1: Percent of Visits with Insured Clients by Study Site, January 2013-July 2014  “A couple of my patients have had surgeries that have allowed them to return to work and now that they have a regular paycheck, they are able to get housed,” Provider, Baltimore Providers reported having access to a broader array of treatment options as a result of Medicaid coverage gains among their patients. With these increased options, providers said they are better able to provide care based on the best courses of treatment rather than based on the availability of charity or discounted resources.  “It’s easier now if I say, take your insurance and go to the pharmacy…instead of me or the nurse having to ll out a bunch of paperwork and apply to the drug company or see what we have in samples and if we’re going to have enough for next time.” Provider, Portland Gains in Medicaid revenue are facilitating strategic and operational improvements focused on quality, care coordination, and information technology. In addition, administrators indicated that Medicaid revenue gains supported sta increases and led https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 2/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation to changing sta roles to meet increased administrative and billing needs. However, participants emphasized that, even with Medicaid revenue gains, other funding sources remain vital for supporting the full range of services needed by the homeless population. Participants from the non-expansion site indicated that their patients remain uninsured and are continuing to face signi cant gaps in care that contribute to poor health outcomes. Participants also said they are facing an increasingly challenging nancial situation because they are missing out on Medicaid expansion revenue gains and other funding sources are declining.  “A lot of it is just outright begging for care for these patients. You just miss that opportunity to pick it up in a more treatable stage.” Provider, Jacksonville (nonexpansion site) As homeless patients gain Medicaid coverage and are enrolled in managed care, some challenges are emerging. Participants commented that some patients are being auto-assigned to providers with whom they do not have an existing relationship and/or they may have di culty accessing due to lack of transportation. Additionally, working within provider networks can be di cult given the complex needs of individuals, lack of transportation, and the limited experience among other providers in serving this population. Lastly, participants emphasized that prior authorization requirements and limited and/or changing drug formularies are leading to delays in care for individuals and creating substantial administrative burdens for providers. Looking ahead, participants identi ed a number of priorities for meeting the health care needs of the homeless population. It was noted that maintaining coverage and educating individuals on how to use coverage will be key for shifting care patterns and reducing emergency room use. Further, maintaining other sources of funding will be key for supporting the full range of services they need. As homeless individuals are increasingly enrolled into managed care, it will be important to address their speci c needs to minimize barriers to care and administrative burdens. Amid the shifting nancial and delivery environment, maintaining supportive and case management services, addressing social determinants of health, and building upon interdisciplinary team-based models of care developed by homeless providers all will be key for engaging individuals in care. Finally, as broader payment and delivery reforms are implemented, it will be important for them to re ect the poorer health status and more complex health needs of the homeless population. Introduction https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 3/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation One of the key goals of the ACA is to expand coverage and reduce the number of uninsured. A primary way the ACA seeks to reduce the number of uninsured is by expanding Medicaid to low-income adults (with incomes at or below 138% of the federal poverty level or $16,105 for an individual or $27,310 for a family of three as of 2014) who were historically ineligible for the program. As enacted, this expansion would occur in all states as of January 1, 2014. However, the Supreme Court ruling on the ACA e ectively made the expansion a state option. As of November 2014, 28 states, including DC, are implementing the expansion. The Medicaid expansion o ers a particularly signi cant opportunity to increase coverage and improve access to care for individuals experiencing homelessness, who historically have had very high uninsured rates and often have multiple, complex physical and mental health needs. A prior brief (https://www.k .org/health-reform/report/medicaid-coverageand-care-for-the-homeless/) examined how homeless health care providers were preparing for the Medicaid expansion and their anticipated impacts of the expansion.1 This brief builds on that previous work to identify early impacts of the expansion for homeless providers and the patients they serve as well as key priorities for meeting the health care needs of the homeless population looking ahead. While the ndings are focused on the homeless community, they o er insights that may help inform understanding of how coverage gains are impacting the broader low-income population. Overview of the Homeless Population Each year, millions of people experience homelessness in the U.S. Though the total number is unknown, the U.S. Department of Housing and Urban Development (HUD) found that 1.48 million people stayed in emergency shelters or transitional housing in 2012.2 However, this estimate excluded individuals who avoided the shelter system, used privately funded shelters not part of HUD’s Continuum of Care network, or who stayed with friends and families to avoid the streets. On a single night in January 2013, HUD estimated 610,042 people were homeless in the U.S., of which 64% were individuals and 36% were part of families.3 This estimate also undercounts the number of people who are homeless, but represents the best attempt to collect national data across all states. People who are homeless have high rates of both chronic disease and acute illnesses, with many of these conditions associated with and/or exacerbated by their living situations. There is a wide body of literature on the health status and conditions of homeless persons, which shows that they have a broad range of mental health and substance use needs that often are co-occurring with physical conditions.4,5 Higher exposure to violence, malnutrition, and extreme weather are additional risk factors for poor health and premature death.6, 7 Often because of poor health and lack of housing, this population also frequents emergency rooms and hospitals more often than the general public, and has high rates of readmissions.8 https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 4/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Prior to Medicaid expansion, homeless individuals were uninsured at high rates even when compared to other low-income groups. Of the 851,641 patients served by Health Care for the Homeless grantees in 2013,9 57% were uninsured, compared to 35% uninsured patients served at all health centers and over four times the rate of the general population (Figure 2).10,11 Despite having access to outpatient primary care and behavioral health services at health centers and other safety net venues, lack of health insurance has prevented this population from accessing the broader range of services needed to address their health conditions, such as specialty care, residential treatment, and surgeries. Being uninsured has also prevented a more systemic analysis of their utilization and cost of care given the lack of coordinated data available through insurers. Finally, connecting this particularly vulnerable group to health insurance is important for the providers who serve them, as they have traditionally relied on unpredictable grant funding and limited pro bono services in the community. Figure 2: Health Insurance Coverage for Health Care for the Homeless Patients Compared to Other Groups, 2013 Methodology To gain insight into the early impacts of the Medicaid expansion for the homeless community, the National Health Care for the Homeless Council  and the Kaiser Commission on Medicaid and the Uninsured conducted focus group discussions with sta and community partners at federally quali ed health centers that serve individuals experiencing homelessness at four sites in states that have expanded Medicaid https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 5/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation (Albuquerque, NM; Baltimore, MD; Chicago, IL; and Portland, OR). Focus groups were also conducted at a site in Jacksonville, FL to gain insight into experiences in a state that has not expanded. In addition, health coverage and administrative data were collected from each of the sites to supplement the focus group ndings. See Appendix Table 1 for and overview of the data. Overall, a total of 118 professionals participated in 14 focus groups held between July and September 2014. Three focus groups were held in each of the four expansion sites—one composed of frontline outreach and enrollment workers, another composed of administrators and nance sta , and the third consisting of clinicians, case managers and other service providers. In Jacksonville, Florida, two focus groups were held—one with administrators, nance sta and clinicians, and another with frontline outreach and enrollment sta . Key Findings Enrollment CHANGES IN COVERAGE Participants in the Medicaid expansion sites reported signi cant gains in health insurance among patients, while there were no reported coverage changes in the non-expansion site. Participants noted that the Medicaid expansion provided a new coverage pathway for many of their previously uninsured patients. In three of the sites, they indicated that state initiatives to facilitate enrollment supported rapid coverage gains under the expansion. Speci cally, in Chicago, the state adopted an option to get an early start on the expansion in Cook County. In Baltimore, individuals enrolled in a preexisting limited bene t program for adults (Primary Adult Coverage program) were automatically transitioned to the Medicaid expansion when it took e ect on January 1st. Finally, in Portland, the state took up an option to utilize data from its Supplemental Nutritional Assistance Program (SNAP) to expedite enrollment into the Medicaid expansion. In contrast to coverage gains at sites in states that expanded Medicaid, participants in Jacksonville said that they have seen no signi cant changes in coverage. The majority of their patients remain uninsured and ineligible for Medicaid in the absence of the expansion. Coverage data from the sites are consistent with participants’ reported coverage changes. As shown in Figure 3, in Baltimore and Portland, the share of site visits with clients who have health insurance rose sharply as of January 2014, re ecting rapid coverage gains from the transition of the existing adult coverage program to the expansion in Maryland and the SNAP facilitated enrollment initiative in Oregon. Albuquerque also shows gains in the share of patients with insurance beginning in January 2014, although the increase is not as sharp. In Chicago, the rise in the share of visits with patients who have insurance begins earlier, at the end of 2012, re ecting the https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 6/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation early expansion in Cook County, and then there are periods of decline that re ect some losses in coverage at renewal periods. In contrast, in Jacksonville, where Medicaid was not expanded, there is no notable increase in the share of visits with insured patients over the period. Figure 3: Percent of Visits with Insured Clients by Study Site, January 2013-July 2014 Looking ahead, outreach workers are focused on maintaining coverage. Although policies are intended to facilitate auto-renewal for eligible individuals, outreach workers expressed signi cant concerns that individuals may lose coverage at renewal, particularly if systems are unable to automatically verify income for individuals. In two of the sites, all individuals will have to re-enroll at redetermination because the state is transitioning to a new enrollment system. Overall, outreach workers were confused about renewal processes and wanted more information to be able to support continuous coverage for individuals. OUTREACH AND ENROLLMENT EXPERIENCES Outreach through a broad range of settings was successful in reaching and enrolling individuals experiencing homelessness, who were generally eager to enroll and access services. Frontline outreach and enrollment workers noted that, in addition to conducting in-reach to enroll patients at their clinic sites, they conducted outreach in a wide range of community locations, including emergency shelters, encampments, under bridges, at parole and probation o ces, day programs/drop-in https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 7/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation centers, hospital emergency rooms, churches, and food pantries or soup kitchens. Participants agreed that having regular outreach schedules and developing trusting relationships with clients was a crucial step in engaging clients, particularly since they had broader goals beyond enrollment of engaging individuals in services. Participants found that individuals were usually interested in enrolling in coverage, although they sometimes had doubts about whether they would qualify or concerns about sharing their information with the government. In particular, individuals were most excited about potentially gaining access to prescription drugs, mental health and substance use services, and dental and vision care. Participants also said that individuals wanted the peace of mind of nancial protection from large medical bills. To facilitate enrollment, assisters spent a considerable amount of time explaining to individuals why health insurance was important, the bene ts of enrolling in coverage, and how the ACA had broadened eligibility for Medicaid compared to when individuals may have previously tried to enroll.  “….We go anywhere that we feel like they need help in our community.” Outreach Worker, Baltimore  “A lot of people haven’t been covered for years; they are just happy that they could get some medical treatment.” Outreach Worker, Portland  “…they’d say ‘oh, so I won’t get all these bills?’ No, you won’t. And so that was a big motivator….”  Outreach Worker, Albuquerque Outreach workers in the Medicaid expansion sites found that nearly all homeless individuals they assisted were eligible for Medicaid, while those in the nonexpansion site found that most of the homeless population remained ineligible for coverage. In the expansion sites, outreach workers reported that nearly all individuals they assisted within the homeless population were eligible for Medicaid, although they did work with some individuals who were not eligible due to immigration status. They also encountered a few cases in which a homeless individual had a job and was just above the income limit for Medicaid. In these cases, coverage through the Marketplace was una ordable, even with the premium subsidies. In Jacksonville, where the state did not expand Medicaid, outreach workers reported that most individuals were not eligible for Medicaid and did not have enough income to qualify for premium tax credits for Marketplace coverage. Enrollment workers in Jacksonville said that many individuals were confused about why they were not eligible for coverage because marketing campaigns were encouraging everyone to enroll, and some were fearful of being ned for not having insurance. They noted that clients were disappointed, angry, and frustrated when learning they were not eligible for coverage. Assisters tried to help connect individuals to https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 8/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation available care by creating resource sheets that listed free or low-cost service sites, but, overall, felt it was di cult to conduct outreach and enrollment e orts when many people do not qualify for coverage. Individuals within the homeless population needed substantial assistance with the application and enrollment process. Outreach and enrollment workers stressed that one-on-one assistance with the application process was key for enrolling individuals, particularly given their limited experience with health insurance and other enrollment barriers, including limited literacy, lack of access to the internet, language barriers, and confusion about coverage options. They further noted that enrollment was hampered by problems with online enrollment systems, particularly at the outset of open enrollment. Although systems problems impacted the broader population, there were some challenges that particularly impacted the homeless population including di culty verifying identity for individuals without a credit history and verifying income for people with no income as well as systems failing to recognize when an individual is no longer incarcerated. Outreach and enrollment workers were hopeful that these system-related issues were short-term and that there would be a smoother enrollment process going forward. Participants said they often tracked the status of applications until a nal eligibility determination was received since individuals may have di culty obtaining communications from the state without a xed address and/or trouble understanding notices. Moreover, in the expansion study sites, after an individual is determined eligible for Medicaid, he or she must then enroll in a managed care plan. Outreach and enrollment workers noted that individuals needed assistance selecting and enrolling in a plan. However, they said it was challenging to determine the di erences between plans and explain them to individuals.  “If you didn’t have signi cant credit history or things like that, it couldn’t verify people’s identity, which just added an extra barrier to getting folks enrolled.” Outreach worker, Baltimore  “We keep a spreadsheet of everybody that we enroll and we keep going back to look if they’ve been approved.” Outreach worker, Albuquerque.  “The paperwork was confusing that they would get in the mail.” Outreach worker, Albuquerque Homeless individuals need signi cant education and assistance to learn how to utilize their health coverage. Participants stressed that many of the homeless individuals who have gained Medicaid coverage have limited or no prior experience with health insurance and have typically delayed and/or gone without needed care and relied https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 9/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation on the emergency room as a primary source of care. As such, they indicated that individuals need education and assistance to establish a relationship with a primary care provider and understand how to receive care and services within their provider network.  “There needs to be an educational piece, because a lot of people haven’t had primary care maybe ever and don’t even really know what it means to have a routine visit with a provider to get those preventative services.” Provider, Baltimore Impacts of Coverage Gains for the Homeless Population Participants reported that gains in Medicaid coverage have led to improved access to care for the patients they serve. Providers noted that gains in Medicaid coverage have enabled their patients to access many services that they could not previously obtain while uninsured, particularly specialty services, behavioral health services, medications, and medical supplies and equipment. They said they are able to get individuals referred for specialty services and screenings such as mammograms and colorectal screenings more quickly and able to make referrals to orthopedists, oncologists, physical therapists, podiatrists, and other specialists that they often were unable to refer to when their patients were uninsured. Some described instances of individuals receiving life-saving or life-changing surgeries or treatments that they could not obtain while uninsured. In particular, providers indicated that coverage has opened up access to mental health services and medications, which are important for this this population. It also was pointed out that coverage of non-emergency transportation helps individuals access needed services, especially from referral providers who may be located in another part of town. Some participants did note challenges nding certain specialists, although they indicated this was re ective of larger provider capacity limits, particularly for mental health and primary care providers. Participants also said that they are beginning to face backlogs in referrals for some services given the large surge in demand for care as people gain coverage. Further, some participants commented that even though Medicaid copayments are often very limited, they can serve as a barrier to care for this population, particularly if an individual is facing copays for multiple prescription medications.  “We had a gentleman who literally was waiting until January 1st and he had an appointment on the second to get oncology testing that he wasn’t able to access in the past.” Provider, Baltimore  “A lot more people are going to get the services that they’ve been needing.” Provider, Portland https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 10/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation  “Now, we can just send them over to [the hospital] which is two, three blocks away.  They can get in that day.” Provider, Chicago  “Any medicated-assisted therapy for substance use, it’s covered now and without that, my clients would have never been able to be successful in recovery.” Outreach worker, Albuquerque Participants also identi ed broader bene ts for individuals stemming from gains in Medicaid coverage. For example, providers said individuals have obtained surgeries and treatments that will resolve medical conditions and improve their ability to work and maintain stable housing. Additionally, participants commented that individuals have less stress about incurring unpaid medical bills or debt. Moreover, they indicated that reductions in medical debt improve individuals’ ability to access housing and employment program opportunities, since their credit is not negatively impacted by medical debt. Participants also said that obtaining Medicaid coverage helps individuals qualify for disability bene ts by facilitating better documentation of their needs. Similarly, in one site, participants noted that Medicaid coverage gains have enabled individuals to get tested for Traumatic Brain Injuries (TBI), which supports their ability to apply for a TBI Waiver program that provides access to housing.  “A couple of my patients have had surgeries that have allowed them to return to work and now that they have a regular paycheck they are able to get housed.” Provider, Baltimore  “That’s something we’re going to start seeing less of—these large hospital bills that are going to negatively impact credit.” Provider, Baltimore  “I feel like they have a much stronger application that we’re turning into Social Security. More medical evidence, for sure.” Outreach worker, Albuquerque Participants said that individuals are more empowered to manage their health and participate in decisions related to their health care as a result of gaining coverage. Providers and enrollment workers described how gaining health coverage and having a choice of plans and providers opened up new personal interest in health care among individuals. Participants recognized that some of this initial excitement may diminish over time, but nonetheless felt that this response provides an important new opportunity for engagement with a population that often has limited choice and control over the options available to them. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 11/28 10/18/2019  Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation “The other thing that is a little bit more intangible is the excitement that patients feel in the choices that they have. They’re feeling quite empowered, they’re extraordinarily excited when they hear the types of things that they now have access to.” Provider, Albuquerque Participants in the non-expansion site described a contrasting experience with individuals continuing to face signi cant barriers to care and poor health outcomes. Participants in Jacksonville noted that, without insurance, individuals continue to rely on limited pro bono services, have di culty accessing needed treatments and specialty services, and utilize the emergency room for dental emergencies and acute mental health stabilization. As such, overall, they experience ongoing poor health, worsening of conditions, and, in some cases, preventable deaths.  “A lot of it is just outright begging for care for these patients. You just miss that opportunity to pick it up in a more treatable stage.” Provider, Jacksonville (nonexpansion site)  “It really is people getting care in all the wrong places at all the wrong times in the most expensive way that they can, and that cost just gets shifted around.” Provider, Jacksonville (non-expansion site) Impacts of Coverage Gains for Providers Providers indicated that they have wider treatment options available to care for their patients as a result of coverage gains. In particular, providers noted that they have much wider choices of medications, since they are no longer limited to medications available through discounted or free pharmaceutical programs. They provided speci c examples, such as being able to prescribe steroid inhalers for asthma or to give monthly injectable mental health medications (rather than daily pills, which have lower compliance rates). With these broader treatment options, providers said they can provide care based on the best course of treatment rather than based on what services or medications they can access through free or discounted programs. They also noted that they have greater ability to provide a stable and consistent treatment plan over time. In contrast, providers in Jacksonville, where Medicaid was not expanded, reported continuing to rely on charity, discounted, and pro-bono services and noted that their treatment choices remained constrained by available resources. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 12/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation  “It’s easier now, if I say, take your insurance and go to the pharmacy and they’ll give you a bottle of pills, instead of me or the nurse having to ll out a bunch of paperwork and apply to the drug company or see what we have in samples and see if we’re going to have enough for the next time.” Provider, Portland  “So it helps not only them, but it helps the primary provider not to feel like we’re practicing frontier medicine, in that we’re actually being helped by the people trained to provide the specialty care that the patients need.  It’s been good for us and for them.” Provider, Baltimore The study sites in Medicaid expansion states are experiencing increases in thirdparty payments as their patients are enrolled in Medicaid. Because the homeless patient population has largely been uninsured, providers serving the population have traditionally relied on a diverse range of public and private grants and donations as the bulk of their revenue. Third-party payments from insurers previously represented a very small percentage of their revenue. Administrators reported that gains in Medicaid coverage are now leading to an increased share of revenue coming from third-party payments, but indicated that other sources of funding, including public and private grants and donations, are declining at the same time. Administrators in Jacksonville, where Medicaid was not expanded, said they are missing out on potential Medicaid revenue gains without the expansion. However, they have experienced some increase in Medicaid revenues by amplifying e orts bill for reimbursable services. Overall, however, administrators in Jacksonville said they are facing an increasingly challenging nancial situation due to declining grant dollars and donations and missed funding opportunities because their state has not expanded Medicaid. Administrators indicated that gains in Medicaid revenue are facilitating longerterm strategic and operational improvements. Administrators noted that their historic reliance on uctuating and unpredictable grant funding made it di cult to invest in structural improvements and plan for growth over the long-term. They commented that the shifts to Medicaid revenue are allowing them to implement longer-term performance improvements because they can plan based on patient volume and need rather than around varying short-term grant requirements. As a result of more stable revenue, they reported engaging in new initiatives focused on improving quality of care, care coordination, and information technology infrastructure. They also cited opportunities to allow clinicians to dedicate some portion of their time to administrative functions, such as care team management and leadership. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 13/28 10/18/2019  Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation “What it’s allowed us to do is to think about growth, organizational growth as driven by volume and not driven by our ability to get another grant.”  Administrator, Baltimore Administrators reported increasing sta ng levels and/or shifting sta responsibilities in response to Medicaid coverage gains. Administrators indicated that gains in Medicaid revenue have created new opportunities to add sta to meet existing needs and expand services. However, they also noted that sta ng needs have changed as a result of increased need for billing managers, data specialists, and care coordination sta . As such, they reported hiring both clinical and administrative sta and/or shifting responsibilities of existing sta . In addition, participants at some of the sites indicated that there is a high level of burn-out among existing sta and signi cant competition for providers in the community, which has increased the importance of strong recruitment and retention policies.  “We believe that, by the end of the year, if we’re hiring all the positions that we have budgeted for, we’ll have 170 sta members up from about 140 last year.” Administrator, Baltimore  “We’ve certainly had to add more providers and behavioral health clinicians to meet increased demand.” Administrator, Portland  “We’ve added…some referrals sta and care coordination sta and also some sta speci cally dedicated to managed care.” Administrator, Chicago Participants emphasized that, even with Medicaid coverage gains, other funding sources remain vital for supporting the full range of services needed by the homeless population. Administrators stressed that Medicaid does not cover the full range of supportive services provided to patients. In particular, they noted that outreach, case management, nursing visits, some behavioral services, and housing and other support services are often not billable services. While they recognized that these services are included in the bundled Medicaid reimbursement health centers receive, participants indicated that the homeless population requires a more intensive level of care than covered by that rate, and pointed out that these services are typically not billable when provided outside a medical visit or by a non-billable provider. They also commented that the state’s Medicaid reimbursement rates rarely cover the full cost of care, particularly for behavioral health and dental care. As such, participants stressed that other sources of funding, including federal, state, and local grants as well as private philanthropy, remain vital to maintaining operations and services even with gains in Medicaid coverage. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 14/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Participants were concerned that decreases in these other funding sources may make it di cult to maintain supportive services going forward and limit resources available for individuals who remain uninsured, including undocumented immigrants.  “The navigation piece and the additional hand-holding and helping them to gure out where they’re supposed to go and that they actually get there is a big piece of work that is unreimbursed.” Administrator, Baltimore  “There’s a sense that oh, you have a windfall of Medicaid now, we don’t need to give you these other funding streams that we gave you that supported your operation.” Administrator, Albuquerque  “The additional needs aren’t reimbursable.” Provider, Chicago ACCESS TO AND DELIVERY OF CARE SUPPORTING ACCESS TO CARE FOR THE HOMELESS POPULATION Participants emphasized that case management and supportive services as well as an open, trusting, and integrated care environment are key for engaging homeless individuals in care. All participants referenced the need for dedicated sta to help patients navigate the system, ll out paperwork, make phone calls, work with managed care plans, obtain necessary paperwork and documentation, conduct needs assessments, assist with transportation to appointments, help re ll medications, connect individuals to other programs and bene ts, and many other activities. Participants also noted that providing an open-access and non-judgmental environment is important. For example, health centers serving this population typically have no copays or out-of-pocket costs, do not issue penalties for late or missed appointments, and emphasize a trusting relationship with patients. Moreover, they described how homeless providers utilize a team-based approach to provide integrated care to address individuals’ physical, behavioral, and social needs.  “It’s very much just open access.” Provider, Baltimore  “It’s not only about making sure that we have the appointment, the important part is making sure they get to the appointment.” Provider, Portland https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 15/28 10/18/2019  Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation “We have lots and lots of warm hando s within the agency and so a person could walk in our door and the same day would have a behavioral health provider and a medical provider, who are crossing over one to the other….” Provider, Albuquerque Participants pointed to the importance of addressing social determinants of health like poverty, hunger, lack of housing, and unemployment to support improved access to care and health outcomes and reduce health costs. Participants stressed that lack of housing is a key impediment to care and improved health for individuals and commented that permanent supportive housing is an e ective model for supporting individuals with signi cant health conditions. Participants noted that Medicaid cannot pay for housing, but that support for housing would reduce costs by preventing repeat hospitalizations and emergency room visits. Participants also pointed out that lack of housing has implications for hospitals who incur longer lengths of stay and higher readmissions when patients have no safe discharge options. In these cases, medical respite programs can provide patients a place to rest and recuperate after surgeries or illnesses, while allowing some time to connect to other resources.1 In addition, hunger and lack of appropriate food were mentioned as challenges for this population, who generally have no place to store food and eat at soup kitchens, which tend to serve highsalt, high-starch diets that exacerbate medical conditions such as hypertension and diabetes.  “If they have some housing or something under their feet, then a lot of the other things can fall into place. It’s really hard to heal somebody’s wound if they’re lying on the street and if they don’t have a place where their medication can be safe.” Provider, Portland  “We can write prescriptions, we can send referrals, get people into specialty services, but if we were actually able to house people that’s the best way to improve their health.” Administrator, Baltimore Although patients have increased choice of providers after gaining Medicaid coverage, most individuals are continuing to rely on providers who serve the homeless population. Participants described some instances of patients seeking care from alternative providers, but then returning to the homeless provider because they felt like they were not treated with respect and did not have a good patient experience at the other provider. Even so, administrators noted that, with the gains in Medicaid coverage, it is increasingly important for safety-net providers to establish themselves as a provider of choice, rather than a provider of last resort. As such, they are focusing on patient satisfaction, care coordination, and quality to provide a rst choice medical home for their patients. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 16/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation  “They were treated like they shouldn’t have been there… they said that it actually started from the front desk all the way to the end of the appointment.”  Administrator, Albuquerque  “We’ve had kind of a public image of being a place you go when you can’t go anywhere else.  Now, we strive to provide great care and we would like to believe our care is as good as anybody else’s.” Administrator, Portland CHALLENGES PROVIDING CARE TO THE HOMELESS POPULATION THROUGH MANAGED CARE In the expansion study sites, individuals gaining Medicaid coverage are enrolled into Medicaid managed care plans. Participants commented that this is leading to some new barriers to care for individuals and administrative burdens for providers as discussed below. Participants noted that some individuals are being automatically enrolled into plans and assigned to a provider but are having di culty accessing care through the assigned provider. Participants commented that individuals may have di culty accessing care through their assigned provider if they do not have an established relationship with the provider, lack transportation, or if the provider’s practice does not accommodate the needs of homeless individuals. Participants have found that it is sometimes challenging for patients to switch providers and that, in some cases, by the time an individual realizes he or she has been auto-assigned to a plan and provider, they are outside the window of time in which they are allowed to make a plan change. As a result, participants reported instances of patients being auto-assigned to a provider, being unable to change their provider back to the health center, and then continuing to utilize the health center as their primary provider. In these cases, the patient may be insured, but the provider remains unable to bill for the services they provide.  “When they were enrolled, a lot of them got assigned to places without their choosing and then to straighten that out was di cult.” Administrator, Portland  “…if they don’t have us listed as their primary care physician and we don’t have a referral on le then we will not be reimbursed for those services.”  Administrator, Chicago Obtaining care through provider networks is posing some speci c challenges for homeless individuals. Participants indicated it is sometimes di cult to nd a network that includes all providers caring for a patient, particularly given the complex needs of the https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 17/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation individuals they serve. Participants also noted that as a result of working within provider networks, there have been shifts in which specialists and hospitals they use to refer patients. In some cases, these shifts are leading to access barriers due to transportation limitations. Further, some patients have found the change di cult because they would prefer to rely on hospitals and providers that they already have experience using. Participants also commented that when individuals receive care from providers who do not have experience serving the homeless population, they sometimes prescribe treatment plans or medications that are not feasible for individuals who are homeless.  “Having only certain providers taking insurance is not speci c to Medicaid, but it’s a big barrier to our patients because of transportation.” Provider, Baltimore  “…they’ll get sent back to us with stu they obviously can’t do… The other providers are not really having an understanding of the special needs of the population.” Provider, Baltimore Participants stressed that prior authorization requirements and drug formularies are leading to delays in care for individuals and creating substantial new administrative burdens. Speci cally, providers said prior authorization requirements delay patients’ access to services, particularly substance abuse treatment, leading to missed opportunities to connect people to care. Providers noted that prior authorization requirements and drug formularies are di erent for each managed care plan, and that it is di cult to stay informed about these di erences because they change frequently. Providers described cases of writing prescriptions for drugs they thought would be covered and then the patient nding out it is not covered when seeking to ll it. Overall, participants reported substantial time and e ort is going toward addressing these requirements, which is taking away from clinical time for providers. Administrators noted that they are hiring sta or shifting existing sta roles to focus solely on these administrative requirements.  “The administrative burden of prior authorizations and the di erent requirements that all the MCOs have…I don’t think we quanti ed it, but I think we’ve seen that administrative burden go up and it’s a challenge for the providers for sure.” Administrator, Baltimore  “If you say, okay, well, this referral we have to do, we have to develop this form, we have to call this number, we have to wait three days, whatever it might be—next thing you know, they’re just saying forget it, and then they’re not getting that need met.” Provider, Chicago https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 18/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Becoming credentialed providers with the managed care plans has been challenging. The study sites in states that expanded Medicaid were seeking to get credentialed with all or most of the Medicaid managed care plans in their area. Participants said the credentialing process has been very challenging and taken a substantial amount of time and administrative resources, particularly since each managed care plan has a separate process and di erent requirements.  “We’re also run into some problems credentialing… and it’s been somewhere between di cult and a nightmare.” Administrator, Chicago Participants said that managed care plans are still developing resources, capacity, and experience to coordinate and manage care for the homeless population. Because the majority of homeless individuals have been ineligible for coverage in the past, Medicaid managed care plans have limited experience serving this population. Participants noted that most plans are not familiar with programs and supportive services, including housing, that are key for managing health care utilization and costs for this population. In one site, participants indicated that plans are required to complete inperson health assessments, which are creating signi cant challenges for homeless individuals, since it is di cult for them to complete the assessment and they are disenrolled if it is not completed. Overall, participants felt some plans have recognized that the homeless population is making up a larger share of their enrollees and are working to increase their understanding of how to manage and support care for this population. However, others have not yet recognized some of the unique challenges and needs of the population. It was noted that obtaining and analyzing utilization, cost, and outcome data and increased collaboration between homeless providers and plans will be key for improving care coordination moving forward. DELIVERY AND PAYMENT REFORM AND DATA SHARING Beyond the Medicaid expansion, broader delivery system changes are impacting homeless providers and patients. Three of the study sites (Chicago, Portland, and Albuquerque) are in states that are implementing new care coordination models within their Medicaid programs that are focused on integrating behavioral and physical services. Further, participants in Baltimore noted that the state is reorganizing its behavioral health system. Participants commented that new coordinated care models are leading to shifts in reimbursements that are tied to outcomes rather than utilization. They stressed that as new delivery and payment models emerge, it will be important for payments to re ect and accommodate the poorer health status and more complex health needs of the homeless population to prevent disincentives for serving high-need individuals. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 19/28 10/18/2019  Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation “A homeless population shouldn’t be judged in an outcome based, value based payment structure like me.  I’ve been involved in preventative healthcare and good healthcare my entire life. …That’s a very unfair equation for providers and creates a real disincentive to serve a very needy population.”  Administrator, Chicago The study sites all have good internal data sharing, but there remain gaps in data sharing with external providers. Participants noted that their health centers have internal electronic health records systems that facilitate providers’ ability to share information and coordinate across primary care, behavioral health and case management services. However, they commented that data sharing with providers outside the health center remains limited. Some are able to view data from multiple hospitals and emergency departments within their communities, while others are only connected to data at one hospital. However, they are only able to view data and do not have the ability to enter data, make changes, or insert notes. As such, coordinating and sharing information with external providers generally still requires phone calls or faxing of reports. Participants felt that increased data sharing would support better care management and continuity of care, particularly among this high-need population and as they begin utilizing care from a wider array of providers. Conclusion and Implications Overall, these ndings show that the Medicaid expansion has already contributed to key bene ts for individuals and providers within the homeless community (Figure 4). Sites in states that expanded Medicaid have experienced signi cant gains in coverage among their homeless patients. Participants report that these coverage gains have led to improved access to care and other broader bene ts, including improved ability to work and maintain housing. Providers feel they have a wider array of treatment options available and that they are better able to provide care based on the best courses of treatment rather than on the availability of charity or discounted services. Administrators note that gains in Medicaid coverage are leading to increases in Medicaid revenue that are supporting longer-term strategic and operational improvements focused on quality, care coordination, and information technology. Increased Medicaid coverage also has supported increases in clinical and administrative sta and led to changing sta roles to meet larger billing and administrative needs. However, even with increased Medicaid revenue, participants stress that other funding sources remain vital for supporting services that are not reimbursable and supporting care for individuals who remain uninsured. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 20/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Figure 4: Impacts of the Medicaid Expansion: Experiences Among Homeless Providers There were sharp contrasts in the experiences of the site where Medicaid was not expanded. Within the non-expansion site, homeless patients remained uninsured. Participants noted that patients continue to face signi cant gaps in care that contribute to poor health outcomes. Providers reported that their treatment options remain largely constrained to pro-bono, charity, and discounted services. Administrators described an increasingly challenging nancial situation, noting that the site is not bene ting from gains in Medicaid revenue that would stem from the coverage expansion and is facing declines in other funding sources. Looking ahead, participants identi ed a range of priorities for addressing the health care needs of the homeless population. They suggested that maintaining stable coverage for individuals and educating individuals on how to use their coverage will be key for shifting care patterns and reducing emergency room use. With regard to nancing, it will be important to maintain other funding sources outside of Medicaid to support the full range of services that are important serving the population. Further, as homeless individuals are increasingly enrolled into managed care, addressing their speci c needs will be key for minimizing barriers to care and administrative burdens. Amid the shifting nancial and delivery environment, maintaining supportive and case management services, incorporating social determinants of health into care models, and building upon the interdisciplinary team-based models of care developed by homeless providers all will https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 21/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation be key for engaging individuals in care. Finally, as broader payment and delivery reforms are implemented, it will be important for them to re ect the poorer health status and more complex health needs of the homeless population. This brief was prepared by Barbara DiPietro of the National Health Care for the Homeless (HCH) Council and Samantha Artiga and Alexandra Gates with the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured. The authors extend their deep appreciation to the individuals and organizations who so generously shared their time and e orts to coordinate and participant in the focus group discussions. Sta time of the National HCH Council author is supported by a Cooperative Agreement with the Health Resources and Services Administration(HRSA), Bureau of Primary Health Care, grant number U30CS09746. The publication’s contents are solely the responsibility of the authors and do not necessarily represent the o cial views of HRSA. Appendix https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 22/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Appendix Table 1: Selected Administrative Data from Study Sites Study Site Number of Patients (2013) 2014 Budgeted Revenue Albuquerque, NM Baltimore,MD Chicago,IL Portland,OR Jacksonville, FL 4,348 10,072 8,570 7,159 5,237 $6,217,575 $15,995,409 $23,084,922 $41,709,430 $3,887,217 Share of Patients with Selected Health Conditions (2013) Hypertension 18% 25% 21% 31% 30% Diabetes 9% 8% 9% 18% 16% Asthma 7% 10% 9% 7% 10% HIV <1% 3% 18% 1% <1% Alcohol-related disorders 13% 12% 5% 32% 4% Hepatitis C 5% 6% 2% 6% 1% Depression/mood disorders 28% 18% 26% 25% 10% Other mental health issues 15% 9% 12% 16% 2% Percentage of Visits with Clients Who have Health Insurance, January 2012-July 2014 Jan-12 5% 51% 36% 60% 0% Feb-12 5% 52% 39% 60% 0% Mar-12 4% 51% 37% 60% 1% Apr-12 4% 50% 38% 60% 1% May-12 4% 53% 36% 59% 0% Jun-12 4% 53% 37% 60% 1% Jul-12 3% 50% 33% 62% 1% Aug-12 4% 53% 33% 61% 1% Sep-12 4% 56% 33% 61% 0% Oct-12 3% 57% 31% 57% 0% Nov-12 2% 57% 35% 57% 0% Dec-12 2% 56% 34% 57% 0% Jan-13 2% 54% 41% 57% 0% Feb-13 3% 56% 44% 57% 0% Mar-13 2% 56% 44% 57% 1% Apr-13 2% 60% 46% 57% 1% May-13 2% 58% 46% 57% 1% Jun-13 3% 56% 50% 57% 1% Jul-13 3% 54% 40% 57% 1% Aug-13 3% 54% 48% 58% 1% https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 23/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Sep-13 4% 51% 50% 58% 1% Oct-13 3% 50% 53% 56% 1% Nov-13 3% 49% 50% 56% 2% Dec-13 5% 51% 50% 56% 2% Jan-14 6% 88% 48% 77% 2% Feb-14 15% 89% 47% 80% 2% Mar-14 23% 89% 51% 83% 2% Apr-14 27% 89% 54% 83% 2% May-14 30% 87% 54% 84% 2% Jun-14 30% 86% 54% 84% 2% Jul-14 31% 87% 47% 84% 3% SOURCE: Data collected from National Health Care for the Homeless study sites, 2014. *The prevalence of health conditions will vary widely from site to site based on numerous factors, to include specialized grants/programming aimed at speci c conditions, the extent of screening and testing available, and the presence of other targeted community resources. Endnotes Introduction 1. Kaiser Family Foundation. (September 2012.) Medicaid Coverage and Care for the Homeless Population: Key Lessons to Consider for the 2014 Medicaid Expansion. Available at: https://www.k .org/health-reform/report/medicaid-coverage-and-carefor-the-homeless/ (https://www.k .org/health-reform/report/medicaid-coverage-and-care-for-thehomeless/). ← Return to text 2. U.S. Department of Housing and Urban Development (HUD), O ce of Community Planning and Development. (September 2013.) The 2012 Annual Homeless Assessment Report (AHAR) to Congress. Available at: https://www.hudexchange.info/resources/documents/2012-AHAR-Volume-2.pdf (https://www.hudexchange.info/resources/documents/2012-AHAR-Volume-2.pdf). ← Return to text 3. U.S. Department of Housing and Urban Development (HUD). (November 2013.) The 2013 Annual Homeless Assessment Report (AHAR) to Congress, Part 1, Point-in-Time Estimates of Homelessness. Available at: https://www.hudexchange.info/resources/documents/AHAR-2013-Part1.pdf (https://www.hudexchange.info/resources/documents/AHAR-2013-Part1.pdf). ← Return to text https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 24/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation 4. U.S. Department of Substance Abuse and Mental Health Services Administration (SAMHSA). (July 2011.) Current Statistics on the Prevalence and Characteristics of People Experiencing Homelessness in the United States. Available at: http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf (http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf). ← Return to text 5. Fazel, S., Geddes, JR, Kushel, M. (October 2104.) "The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations." The Lancet 384 (9953 (http://www.thelancet.com/journals/lancet/issue/vol384no9953/PIIS0140-6736(14)X6109-X)), 1529 1540. Available at: http://www.thelancet.com/journals/lancet/article/PIIS01406736(14)61132-6/abstract (http://www.thelancet.com/journals/lancet/article/PIIS01406736(14)61132-6/abstract) ← Return to text 6. O’Connell, J.J. (Ed.) (2004.) “The health care of homeless persons: A manual of communicable diseases and common problems in shelters and on the streets.” The Boston Heath Care for the Homeless Program.  Available at: http://www.bhchp.org/BHCHP%20Manual/pages/chapters_sections.html (http://www.bhchp.org/BHCHP%20Manual/pages/chapters_sections.html). ← Return to text 7. Morrison, D.S. (2009.) “Homelessness as an independent risk factor for mortality: Results from a retrospective cohort study.” International Journal of Epidemiology, 28(3), 877-883. ← Return to text 8. Ku. B, et al. (May-June 2010.) Factors Associated with Use of Urban Emergency Departments by the U.S. Homeless Population. Public Health Reports 125: 398-405. Available at: http://www.publichealthreports.org/issueopen.cfm?articleID=2402 (http://www.publichealthreports.org/issueopen.cfm?articleID=2402). ← Return to text 9. Known as “Health Care for the Homeless” grantees, these health centers are a special populations category of the health center program, administered by the Health Resources and Services Administration (HRSA). More information about HCH grantees can be found at http://bphc.hrsa.gov/about/specialpopulations/index.html (http://bphc.hrsa.gov/about/specialpopulations/index.html). ← Return to text 10. U.S. Department of Health and Human Services, Health Resources and Services Administration. (2013.) Table 4: Selected Patient Characteristics, 2013 National Homeless Data. Available at: http://bphc.hrsa.gov/uds/datacenter.aspx? q=t4&year=2013&state=&fd=ho (http://bphc.hrsa.gov/uds/datacenter.aspx? q=t4&year=2013&state=&fd=ho). https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 25/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation ← Return to text 11. U.S. Department of Health and Human Services, Health Resources and Services Administration. (2013.) Table 4: Selected Patient Characteristics, 2013 National Data. Available at: http://bphc.hrsa.gov/uds/datacenter.aspx?q=t4&year=2013&state (http://bphc.hrsa.gov/uds/datacenter.aspx?q=t4&year=2013&state). ← Return to text Key Findings 1. Medical respite care is acute and post-acute medical care for homeless persons who are too ill or frail to recover on the street from a physical illness or injury. Unlike “respite” for caregivers, “medical respite” is short-term residential care that allows homeless individuals the opportunity to rest in a safe environment while accessing medical care and other supportive services. Medical respite care is o ered in a variety of settings, to include freestanding facilities, homeless shelters, nursing homes and transitional housing. More information is available at https://www.nhchc.org/resources/clinical/medical-respite/ (https://www.nhchc.org/resources/clinical/medical-respite/). ← Return to text GET THE LATEST ON HEALTH POLICY Sign Up For Email Alerts Enter email address... SIGN UP  FOLLOW KFF Twitter Facebook Instagram Email Alerts Feeds https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 26/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation Feeds © 2019 KAISER FAMILY FOUNDATION Powered by WordPress.com VIP CITATIONS AND REPRINTS PRIVACY POLICY The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94170 Phone 650-854-9400 Washington O ces and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 Phone 202-347-5270 www.k .org Email Alerts: k .org/email facebook.com/KaiserFamilyFoundation twitter.com/k the Kaiser Family Foundation is a nonpro t organization based in San Francisco, California. https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 27/28 10/18/2019 Early Impacts of the Medicaid Expansion for the Homeless Population The Henry J. Kaiser Family Foundation https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 28/28 Jonathan Reeve From: Sent: To: Subject: Attachments: Gary Dougherty Friday, October 18, 2019 3:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments - TennCare II Demonstration Amendment 42 ADAComments-TNBlockGrant-101819.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   On behalf of the more than 30 million Americans living with diabetes and the 84 million more with prediabetes, the  American Diabetes Association (ADA) provides the attached comments on the Tennessee Department of Health and  Human Service’s TennCare II Demonstration Amendment 42.    Please let me know if you have any questions at all.    Thank you.      Gary Dougherty Director State Government Affairs Phone: +1 (800) 676-4065 x4832 Mobile: +1 (614) 726-0801 diabetes.org 1-800-DIABETES (800-342-2383) Are you at risk for Type 2 Diabetes? Take the Test     1 October 18, 2019 Director Gabe Roberts Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Director Roberts: On behalf of the more than 30 million Americans living with diabetes and the 84 million more with prediabetes, the American Diabetes Association (ADA) provides the following comments on the state of Tennessee’s Department of Health and Human Service’s (Department) TennCare II Demonstration Amendment 42. As the global authority on diabetes, the ADA funds research to better understand, prevent and manage diabetes and its complications; publishes the world’s two most respected scientific journals in the field, Diabetes and Diabetes Care; sets the standards for diabetes care; holds the world’s most respected diabetes scientific and educational conferences; advocates to increase research funding, improve health care, enact public policies to stop diabetes, and end discrimination against those denied their rights because of the disease; and supports individuals and communities by connecting them with the resources they need to prevent diabetes and better manage the disease and its devastating complications. According to the Centers for Disease Control and Prevention (CDC), over 11.6% of adults in Tennessee have diagnosed diabetes.1 Access to affordable, adequate health coverage is critically important for all people with, and at risk for, diabetes. Adults with diabetes are disproportionally covered by Medicaid.2 For low-income individuals, access to Medicaid coverage is essential to managing their health. As a result of inconsistent access to Medicaid across the nation, these low-income populations experience great disparities in access to care and health status, which is reflected in geographic, race and ethnic differences in morbidity and mortality from preventable and treatable conditions. The ADA is concerned with Tennessee’s waiver proposal as it would put vulnerable Tennesseans at risk for loss of essential coverage and services. Block Grant The state proposes to alter its federal funding, a flexible federal match rate, to a fixed lump sum. The ADA has deep concerns about funding state Medicaid programs with a capped mechanism. Medicaid’s current financing structure is nimble and can 2451 Crystal Drive Suite 900 Arlington, VA 22202 1-800-DIABETES (342-2383) respond to the economy or varying demographics of program enrollees. Medicaid spending is often impacted beyond the control of government officials, including shifts in the state economy or within the healthcare system. Alternative Medicaid financing models like block grants don’t keep up with the states’ increased healthcare costs, so federal funding of the program is slowly cut over time.3 If a state’s costs exceed the amount of federal funding, it must use its own funds to make up the difference, or cut healthcare coverage or eligibility for Medicaid enrollees,4 putting the ability of low-income individuals with diabetes to access the care necessary to manage their disease at risk. The ADA strongly urges the Department to reconsider the proposed financing structure as it will have a negative impact on TennCare enrollees seeking care. Drug Formulary The waiver proposes a closed formulary to exclude high-cost drugs from coverage. It is important to note Section 1927 of the Social Security Act, which requires Medicaid to cover Food and Drug Administration approved drugs (subject to certain conditions and exclusions) if the manufacturer of such drugs has signed an agreement to pay rebates, is not waivable under Section 1115.5 Moreover, Section 1115 gives the Secretary authority to waiver sections of the statute for demonstration projects that are “likely to assist in promoting the objectives of [Medicaid].” The proposal would exclude high-cost drugs from coverage until “market prices are consistent with prudent financial administration” or until “sufficient data exist regarding the cost effectiveness of the drug,” therefore shifting the cost of these drug onto the enrollees who need them and who cannot afford them.6 Day-to-day management of diabetes is a heavy burden that rests squarely with the individual living with the disease. The complexities of managing diabetes are unique to each individual, based on health history, phenotype, co-morbidities, lifestyle, and other important factors. It is critical that people with diabetes have the opportunity to work with their health care providers to choose the most appropriate therapeutic option that best meets their individual needs at that particular time. Thus, a patientcentered approach, in consultation with a multidisciplinary diabetes care team, should be the guiding principle for making treatment choices. Developing an individual’s diabetes management plan should take into account the patient’s age, cognitive abilities, school/work schedule and conditions, health beliefs, support systems, eating patterns, physical activity, social situation, financial concerns, cultural factors, literacy and numeracy skills, diabetes complications, comorbidities, health priorities, other medical conditions, preferences for care, and life expectancy. 2451 Crystal Drive Suite 900 Arlington, VA 22202 1-800-DIABETES (342-2383) Each year the ADA publishes Standards of Medical Care in Diabetes (Standards of Care) to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. These guidelines meet the Institute of Medicine standards for guideline development, have an evidence base with documented validity over time, incorporate multiple comorbidities, and have become the international gold standard for diabetes management. The Standards of Care undergo a formal review process by the ADA’s Professional Practice Committee which performs an extensive literature search and updates the Standards of Care annually based on the quality of new evidence. As it relates to medication therapy, the ADA’s 2019 Standards of Care identifies multiple factors which must be considered by a clinician when determining the appropriate medications for an individual with diabetes, including efficacy, risk of hypoglycemia, impact on weight, side effects, and cost.7 Implementing a closed formulary that includes as few as one drug per therapeutic class will severely hinder prescribers’ and TennCare enrollees’ ability to choose the most appropriate medication(s) for the individual, jeopardizing the health of individuals with diabetes. The ADA strongly urges the Department to rescind the proposal to bypass the requirements of Section 1927 and severely restrict TennCare enrollees’ access to prescription drugs by implementing a closed formulary. Medicaid Expansion The proposal does not address the state’s coverage gap and would continue to leave more than 200,000 low-income adults in Tennessee uninsured.8 Medicaid expansion made available through the Affordable Care Act (ACA) offers promise of significantly reducing disparities in access to care and health status. Specifically, in Medicaid expansion states, more individuals are being screened for and diagnosed with diabetes than states that have not expanded.9 Additionally, a recent study found expansion states have a higher rate of prescription fills for diabetes medications than non-expansion states.10 Regular medication use with no gap in health insurance coverage leads to fewer hospitalizations and less use of acute care facilities.11,12 Rather than implementing changes that impose significant barriers to obtaining and maintaining Medicaid coverage, the ADA recommends the state work to ensure all low-income individuals in Tennessee have access to adequate, affordable health care coverage through full Medicaid expansion. Conclusion Diabetes is a complex, chronic illness that requires continuous medical care.13 Medicaid enrollees with diabetes cannot afford a sudden gap in health insurance 2451 Crystal Drive Suite 900 Arlington, VA 22202 1-800-DIABETES (342-2383) coverage. A recent study found that patients with type 1 diabetes who experience a gap or interruption in coverage, are five times more likely than those with continuous coverage to use acute care services (i.e. urgent care facilities or emergency departments).14 Adding administrative barriers and burdens will impede access to health services that Tennessee residents with diabetes need. We strongly urge the Department to retract the Section 1115 Demonstration Waiver proposal as it creates barriers to accessible, affordable, and adequate healthcare for low-income Tennessee residents with diabetes who rely on the program. The ADA appreciates the opportunity to comment on the Department’s Waiver. Our comments include numerous citations to supporting research, including direct links to the research for the benefit of the Department in reviewing our comments. We direct the Department to each of the studies cited – made available through active hyperlinks – and we request that the full text of each of the studies cited, along with the full text of our comments, be considered part of the administrative record in this matter for purposes of the Administrative Procedure Act. If you have any questions, please contact me at GDougherty@diabetes.org or +1 (800) 676-4065 x4832. Sincerely, Gary Dougherty Director, State Government Affairs 1 Center for Disease Control and Prevention, Diagnosed Diabetes. Available at: https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html 2 Kaiser Commission on Medicaid and the Uninsured, The Role of Medicaid for People with Diabetes, November 2012. Available at http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8383_d.pdf. 3 Medicaid and CHIP Payment and Access Commission, Alternative Approaches to Federal Medicaid Financing, June 2016, available at: https://www.macpac.gov/publication/alternative-approaches-tofederal-medicaid-financing 4 Rosenbaum S, Schmucker S, Rothenberg S and Gunsalus R, What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid? The Commonwealth Fund, November 2016, available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/nov/medicaid-block-grants 5 PhRMA .v. Thompson, 251 F.3d 219, 222 (D.C. Cir. 2001). 2451 Crystal Drive Suite 900 Arlington, VA 22202 1-800-DIABETES (342-2383) Tennessee Department of Health and Human Services, Division of TennCare, TennCare II Demonstration, Amendment 42 Draft, September 2019. Available at: https://www.tn.gov/content/dam/tn/tenncare/documents2/TennCareAmendment42.pdf 7 American Diabetes Association, Standards of Medical Care in Diabetes – 2019, Diabetes Care, January 2019. Available at: https://care.diabetesjournals.org/content/27/suppl_1/s15 8 Buettgens M., The Urban Institute, “The Implications of Medicaid Expansion in the Remaining States: 2018 Update,” May 2018. Available at: https://www.urban.org/sites/default/files/publication/98467/the_implications_of_medicaid_expan sion_2001838_2.pdf 9 Kaufman H., Chen Z., Fonseca V. and McPhaul M., Diabetes Care, “Surge in Newly Identified Diabetes Among Medicaid Patients in 2014 Within Medicaid Expansion States Under the Affordable Care Act,” March 2015. Available at: http://care.diabetesjournals.org/content/early/2015/03/19/dc14-2334 10 Myerson R., Tianyi L., Tonnu-Mihara I., and Huang E.S., Health Affairs, Medicaid Eligibility Expansions May Address Gaps in Access to Diabetes Medications, August 2018. Available at: https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2018.0154 11 Id. 12 Rogers M, Lee J, Tipirneni R, Banerjee T, and Kim C, Health Affairs, Interruptions in Private Health Insurance and Outcomes In Adults with Type 1 Diabetes: A Longitudinal Study. July 2018. Available at: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.0204 13 American Diabetes Association, Standards of Medial Care in Diabetes – 2018, Diabetes Care, January 2018, available at: http://care.diabetesjournals.org/content/41/Supplement_1. 14 Rogers M, Lee J, Tipirneni R, Banerjee T, and Kim C, Health Affairs, Interruptions in Private Health Insurance And Outcomes In Adults with Type 1 Diabetes: A Longitudinal Study. July 2018. Available at: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.0204 6 2451 Crystal Drive Suite 900 Arlington, VA 22202 1-800-DIABETES (342-2383) Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Michael McKnight Friday, October 18, 2019 3:39 PM PUBLICE NOTICE TENNCARE Ruth Ann Norton; Kiersten Sweeney [EXTERNAL] Comments from Green & Healthy Homes Initiative on Amendment 42 TennCare comments.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   On behalf of President and CEO Ruth Ann Norton, please find attached comments from the Green & Healthy Homes  Initiative on Amendment 42.    Thanks,  Mike    Michael McKnight   Vice President of Policy and Innovation   1612 K St NW, Suite 902, Washington, DC 20006  (202) 769‐5763   mmcknight@ghhi.org  website   facebook   twitter  Instagram   linkedin   donate   volunteer         ******************************************************************** This e-mail and any attachments within are intended solely for the use of the addressee and may contain privileged, confidential, copyrighted, trademarked, or other legally protected information. If you are not the intended recipient (even if the e-mail address above if yours), you may not use, copy or retransmit it. If you have received this by mistake please notify me by return e-mail, then delete. Thank you. ********************************************************************   1 October 2019 TennCare Amendment 42 Comments As stated in Amendment 42, TennCare wants to have the flexibility to invest in health, not just healthcare. Critical to this mission is providing Tennesseans with services that address the social determinants of health (SDOH), which are often being effectively provided at the community level but are not paid for by Medicaid. While Amendment 42 speaks to potentially covering new services, it does not mention allowing Managed Care Organizations (MCOs) to use Medicaid dollars to pay non-traditional (e.g. community-based organizations) providers to deliver services that address SDOH. Given that many of these services improve health outcomes and reduce costs, it is important that they are included as allowable Medicaid expenses. As an example, a healthy housing organization operating in Tennessee may use community health workers to provide evidence-based, in-home asthma education and employ environmental assessors and contractors to address and remediate unhealthy and unsafe housing conditions. This type of intervention has been proven to improve health and reduce costs related to unnecessary hospital and emergency department utilization but is not typically paid for by Medicaid. Direct health care investment would allow the highest-utilizing Medicaid beneficiaries across the state access to these services. If MCOs are allowed the discretion to pay non-traditional providers to deliver services that address the SDOH to members, it is important that investments in these services be counted as medical and not fall under administrative. This would ensure rates for the following years will not be negatively impacted if the investments lead to lower costs, incentivizing MCOs to continue to invest in these services. Given the importance of addressing the SDOH across the state, many non-traditional providers delivering these successful, evidence-based services will need to scale to meet demand. Explicitly allowing third party funders to invest in these SDOH services will ensure organizations can meet the need in Tennessee without increasing costs for TennCare. We believe that the potential for health improvements and cost savings in Tennessee will be limited if MCOs are not empowered to invest in services that address the SDOH. We recommend allowing MCOs to pay nontraditional providers for services that improve health outcomes and reduce cost and to count those payments as medical. 1 Jonathan Reeve From: Sent: To: Subject: Attachments: Heather Powell Friday, October 18, 2019 3:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Public Comment Submission - Tennessee Kidney Foundation TennCare Block Grant Proposal Comments - Tennessee Kidney Foundation.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Tennessee Kidney Foundation (TKF) appreciates the opportunity to submit the attached comments on the  TennCare II Demonstration Amendment 42 (Project No. 11‐W‐00151/4). Thank you.    Heather Corum Powell   CEO   Tennessee Kidney Foundation  37 Peabody Street, Suite 206   Nashville, TN 37210  @tnkidney   tennesseekidneyfoundation.org  O: 615.383.3887           Maury County – Saturday, October 19  Nashville – Saturday, November 2      1 37 Peabody Street, Suite 206 Nashville, TN 37210 P: 615.383.3887 F: 615.383.2647 tennesseekidneyfoundation.org @tnkidney October 18, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: Tennessee Kidney Foundation (TKF) appreciates the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4). The prevalence of kidney disease in Tennessee is among the highest in the country, and the incidence of kidney failure increases by at least 10-15% annually with more than 4,700 Middle Tennesseans and 10,000 Tennesseans statewide currently affected by kidney failure and as many as 1,000,000 more with diagnosed or undiagnosed chronic kidney disease. With more than 4,700 patients in Middle Tennessee alone receiving lifesaving dialysis three times weekly for their end stage renal disease, TKF is a lifeline for individuals, providing access to care through transportation and financial assistance in tackling the hardships of their disability. TKF is also a source for preventive health screening resources and education about managing or preventing chronic kidney disease. Tennessee Kidney Foundation is committed to ensuring that End Stage Renal Disease (ESRD) patients in Tennessee receive quality and affordable healthcare coverage. TKF is concerned about the potential negative consequences of this proposal to convert the funding structure of the TennCare program to a block grant and how that will jeopardize beneficiaries’ access to care. Potential negative impact to (ESRD) beneficiaries is especially concerning because ESRD has no cure, and the only available treatment options are 1) dialysis for the duration of a person’s life or 2) kidney transplantation. The level of care required to sustain the lives of dialysis patients is critical, and the nature of the disease and duration and frequency of treatments prohibits most patients from continuing employment. Any disruption in treatment for an ESRD patient can be extremely harmful and even lifethreatening given that life-sustaining medical care is required multiple times per week. Thank you for helping Tennessee Kidney Foundation empower and support those at risk or affected by kidney disease. 37 Peabody Street, Suite 206 Nashville, TN 37210 P: 615.383.3887 F: 615.383.2647 tennesseekidneyfoundation.org @tnkidney TKF is concerned that the state will cut or reduce coverage for vital services and benefits including transportation to this life-saving care, making it even more difficult for patients to access the care that they need. Beyond the risks to the lives of ESRD patients who cannot access care, the costs of healthcare increase exponentially when ESRD patients become hospitalized as a result of missed treatments. ESRD patients are a highly vulnerable group who would be deeply affected by any reduction in services, and protecting their interests is of utmost importance. As the gap between the block grant and actual costs of care increases over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients will only increase. Cutting programs appears to be inevitable in that case, and this is deeply concerning. The per capita adjustments to the block grant will not be enough if an event, such as an unanticipated increase in the rate of ESRD, occurs in Tennessee. TKF is further concerned about the proposal to create a closed formulary. Limiting access to medications will be detrimental to individuals with ESRD, who are required to take multiple medications each day and often live with numerous comorbidities requiring additional medications. Finally, TKF is concerned that health outcomes for the most vulnerable individuals – children and adults alike - battling chronic disease are secondary to potential financial savings, especially given that health outcomes will not play a role in determining the cost savings to the State of Tennessee. Any potential shared savings will not necessarily be restricted to improving health outcomes, so TKF is concerned that the overall objective of this program is fiscally focused when hundreds of thousands of lives are at stake. We appreciate your consideration of our comments and welcome the opportunity to discuss our concerns. Sincerely, Heather Corum Powell Chief Executive Officer Tennessee Kidney Foundation Thank you for helping Tennessee Kidney Foundation empower and support those at risk or affected by kidney disease. Jonathan Reeve From: Sent: To: Subject: Attachments: Kimberly Ramseur Friday, October 18, 2019 10:02 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Tennessee Block Grant Letter.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good Morning,    Attached are comments regarding the TennCare II Demonstration Amendment 42 (Project No. 11‐W‐00151/4) made on  behalf Hemophilia Federation of America, the National Hemophilia Foundation, and the Tennessee Hemophilia  Foundation.     Thanks,    Kimberly Ramseur, JD, MPH   Senior Manager for Policy & Advocacy   Hemophilia Federation of America  999 North Capitol Street NE, Suite 201   Washington, DC   20002  DC Office: 202.675.6984   Mobile: 404.985.9704  www.hemophiliafed.org    1 October 18, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: Founded in 1970, Tennessee Hemophilia & Bleeding Disorders Foundation (THBDF) is a non-profit 501(c)(3) organization that assists, educates, and advocates on behalf of those living with bleeding disorders, such as hemophilia and von Willebrand disease. One of THBDF’s goals is to seek to advance community and public dialogue on the issues that impact Tennesseans with bleeding disorders, specifically issues related to access quality and affordable health care coverage. HFA and NHF are national non-profit organizations that represent individuals affected by bleeding disorders across the United States. Our missions are to ensure that individuals affected by hemophilia and other inherited bleeding disorders have timely access to quality medical care, therapies, and services, regardless of financial circumstances or place of residence. THBDF, HFA, and NHF appreciate the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4). The purpose of the Medicaid program is to provide healthcare coverage for low-income individuals and families. Our organizations are committed to ensuring that TennCare provides quality and affordable healthcare coverage. Unfortunately, this waiver proposal to convert the funding structure of the TennCare program to a block grant will jeopardize beneficiaries’ access to care. THBDF, HFA, and NHF therefore oppose Tennessee’s proposal and offer the following comments. Block Grant Structure We oppose Tennessee’s proposal to change the financing structure for its Medicaid program to a block grant. THBDF, HFA, and NHF fear that the block grant structure increases the risk that the state might cut coverage for certain treatments completely or impose additional barriers to important services, making it more difficult for patients to access the care that they need. Tennessee’s vulnerable bleeding disorders population – as a small community with high cost health needs – could be particularly at risk of budget-driven cuts in services.i Additionally, Tennessee might choose to cut payments to providers to help keep spending under the new block grant, impacting patient access to the specialized providers who treat bleeding disorders.ii As the gap between the block grant and actual costs of care increased over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients would also increase.iii These cuts would cause unacceptable harm to Tennessee’s Medicaid beneficiaries with bleeding disorders. Tennessee’s proposed structure would not protect either the state or beneficiaries from financial risk. The per capita adjustments to the block grant would not be sufficient if an unexpected event increases per person 1 healthcare costs. For example, there are many ground-breaking treatments in development for a variety of serious health conditions, including for hemophilia. If an expensive but highly effective treatment became available, Tennessee’s anticipated spending could rise, putting the state’s budget at risk and creating an incentive for the state to limit or deny access to that treatment. Tennesseans with bleeding disorders, denied access to these therapies, would be consigned to living with impaired health, permanent mobility issues or even death. Our community cannot afford to take this gamble on their health. Tennessee’s proposal would include vulnerable eligibility groups such as children and people with disabilities in the block grant. As noted above, we have serious apprehensions about how this would impact care for people with bleeding disorders – a small but high need and high cost population. Our concerns are especially acute since, under this proposal, current and future administrations would not need to get approval to make changes to benefits and services. Finally, we also share concerns voiced by other patient groups that TennCare cannot be changed to a block grant structure through the 1115 waiver process. The US Secretary of Health and Human Services is not permitted to waive Sections 1903 and 1905 (the laws that spell out the financing structure of the Medicaid program) via waiver, as multiple experts have noted.iv,v Such a change would require congressional authority, yet Congress has repeatedly declined to pass legislation on this issue, most recently during the debate over repealing and replacing the Affordable Care Act in 2017. Prescription Drug Access THBDF, HFA, and NHF oppose the proposal to create a closed formulary with as few as one drug per class, and to exclude prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated approval process. Limiting access to medications would be extremely detrimental to the bleeding disorders community, putting patient health at risk and potentially raising overall medical costs for this patient population. Prescription drugs that treat bleeding disorders have different indications, different mechanisms of action, and different side effects, depending on the person’s diagnosis and comorbidities. Hemophilia treatments, for example, vary in a number of important respects, including half-life and immunogenicity. No generic treatments exist, and the various products are not therapeutically equivalent or interchangeable. Restricting TennCare’s drug benefits to a closed formulary would therefore harm bleeding disorders patients by limiting the ability of providers to make the best medical decisions for the care of their patients, effectively taking clinical care decisions away from the doctor and patient and giving them to the state. Excluding prescription drugs approved through FDA’s accelerated processes could deny Tennesseans with bleeding disorders access to innovative and life-changing new therapies. These limitations could be devastating for people with bleeding disorders. Additionally, it appears that the waiver proposal omits any appeals process for patients to access prescription drugs that are no longer covered. Because a one-size-fits-all approach does not work for bleeding disorders patients, it is unacceptable to limit access to treatments via a closed formulary – particularly without providing an appeals process by which patients can access off-formulary, medically necessary medications. 2 State Flexibilities THBDF, HFA, and NHF oppose a number of proposals in the waiver application considered under the broad moniker of “state flexibilities.” Tennessee is asking to be exempt from federal standards and requirements for its managed care program, including the Managed Care Rule. This important safeguard ensures Medicaid Managed Care Organizations (MCOs) have to meet certain requirements related to patient care. For example, the managed care rule sets standards related to adequate networks, so patients can actually see the appropriate providers and receive the care they need. The managed care rule requires MCOs to comply with standards of time and distance to measure this network adequacy, helping patients access both primary care providers and specialists they need. This is especially important for our members when they are looking for a provider that treats their specific needs. Requiring oversight of MCOs to ensure that their networks are meeting the health care needs of the populations it claims to serve should be a very high priority. Tennessee is asking to change the “amount, duration, and scope” of benefits, which could allow the state to put caps on services or only cover critical services for certain individuals. The Medicaid population, by definition, is a vulnerable population, allowing Tennessee to change the “amount, duration, and scope” of benefits could impact negatively impact patient care and outcomes. THBDF, HFA, and NHF fear for the health and well-being of Tennesseans with bleeding disorders if the state opts to place caps on health care services or to limit access to the life-saving treatments they need to survive. Finally, the state would no longer need to get approval to make changes to benefits and services in the future and would like to make this demonstration permanent, removing important opportunities for the public to provide feedback on the how the program is working for key stakeholders before any policies are implemented or continued. It is especially important that beneficiaries impacted by the demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint venture between Tennessee and CMS. Both entities, as well as the people it serves, should have a voice in how the program is administered. Fiscal Sustainability If Tennessee is truly concerned about the fiscal sustainability of its Medicaid program, the state could submit a state plan amendment to fully expand Medicaid to 138 percent of the federal poverty level and receive a 90 percent match from the federal government for all expenses for the adult expansion population. This policy would both benefit the state financially and extend access to care to more low-income individuals in need of coverage, a core objective of the Medicaid program. Tennessee has also failed to provide a complete budget neutrality estimate with details of the projected changes in spending with the waiver and any impact on coverage. The federal rules at 431.408 pertaining to state public comment process require at (a)(1)(i)(C) that a state include an estimate of the expected increase or decrease in annual enrollment and expenditures if applicable. The intent of this section of the regulations is to allow the public to comment on a Section 1115 proposal with adequate information to assess its impact. Given that this waiver represents a fundamental change to Tennessee’s demonstration, the state should include these projections and their impact on budget neutrality provisions. 3 The core objective of the Medicaid program is to furnish healthcare to low-income and needy populations. THBDF, HFA, and NHF oppose Tennessee’s proposed block grant waiver as inconsistent with that core objective. Thank you for the opportunity to submit comments. Sincerely, Kim Isenberg Vice President, Policy, Advocacy & Government Education Hemophilia Federation of America 999 North Capitol Street, NE Suite 201 Washington, DC 20002 Teresa Nothan Executive Director Tennessee Hemophilia Foundation 242 Heritage Park Drive Suite 105 Murfreesboro, TN 37129 i Nathan Schaefer Vice President of Public Policy National Hemophilia Foundation 7 Penn Plaza Suite 1204 New York, NY 10001 See blog post by David Anderson, “Medicaid Block Grants: Tennessee Edition,” https://www.balloon-juice.com/2019/05/06/medicaid-blockgrants-tennessee-edition/ (accessed Oct. 16, 2019). ii See id.: “Expensive services that help few people and are not seen as randomly distributed and randomly occurring would be the logical target of a state trying to spend as little as possible while not angering too many people.” iii “Tennessee is one of only two states that has ever had a large-scale planned disenrollment from its Medicaid program, which occurred in 2005 and 2006 because of budgetary stress. . . .Patient and provider advocates in Tennessee argue that future budget stresses could again result in cuts and that the state will have even greater incentive to cut benefits and reduce eligibility for the groups covered by the block grant.” Melinda B. Buntin, “Tennessee’s Opening Bid for a Medicaid Block Grant,” New Eng. J. of Med., Oct. 9, 2019, https://www.nejm.org/doi/full/10.1056/NEJMp1913356?query=TOC (accessed Oct. 16, 2019). iv Joan Alker. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown University Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/ pending-cms-guidance-on-medicaid-block-grants-executive-overreach-strikes-again/. v https://theincidentaleconomist.com/wordpress/tennessee-wants-to-block-grant-medicaid-is-that-legal/ 4 Jonathan Reeve From: Sent: To: Subject: Attachments: Cutillo, Anthony Friday, October 18, 2019 2:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant Additional Comments- HMS TennCare Block Grant Additional Comments - HMS.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare,    HMS would like to submit additional comments regarding Tennessee’s block grant waiver application. Please find them  attached to this email. If you have any questions or concerns please do not hesitate to contact me at this email or any  phone number provided below.    Thank you,        Anthony Cutillo  Government Relations Coordinator  1101 14th St NW  Washington, DC 20005  Anthony.cutillo@hms.com  Work: 202‐448‐2023  Mobile: 508‐455‐7995    Please note that the information contained in this message is intended only for the use of the person or office to whom  it is addressed, and may contain privileged and confidential information protected from disclosure under the law,  including the Health Insurance Portability and Accountability Act (HIPAA). All recipients are hereby notified that any  inadvertent or unauthorized receipt does not waive such privilege, and that unauthorized dissemination, distribution or  copying of this communication is strictly prohibited and may subject you to criminal or civil penalties.     If you have received this communication in error, please notify the sender by replying to the message and delete the  material from any computer. HMS Holdings Corp., together with its subsidiaries and affiliates hereby claim all applicable  privileges related to this information. Any views expressed in this message are those of the individual sender, except  where the sender specifies, and with authority, states them to be the views of the company.  1 October 18, 2019 Mr. Gabe Roberts Deputy Commissioner Department of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Commissioner Roberts: HMS appreciates the opportunity to provide comments on TennCare’s recently released TennCare II Demonstration waiver proposal. HMS recognizes the heavy burden that H.B. 1280 has placed on TennCare in the creation of a waiver that will provide the regulatory flexibility that the General Assembly desires, the assurance that benefits and services will continue uninterrupted, and the realization of cost savings that taxpayers demand. HMS has nearly 40 years of experience serving over 40 Medicaid programs, the Children’s Health Insurance Program, and Medicare. We also serve the Veterans Health Administration, 325 health plans, and over 150 self-insured employers. In Tennessee, HMS has served as a trusted partner for 13 years and has recovered or cost avoided over $6 billion for TennCare during that time. Harnessing innovative technology, analytics, and engagement solutions, HMS provides a broad range of coordination of benefits, payment integrity, care management, and member engagement solutions that help achieve the triple aim of lower costs, improved quality, and enhanced patient outcomes and satisfaction. After reviewing the proposed draft waiver, we would like to offer the following comments. We hope these are helpful as you continue in your efforts to draft the waiver. Please know that we are certainly available to address any questions you may have regarding these or other possible suggestions as well as provide you with any additional information you may need. Thank you for the opportunity to express our views and for the continuing opportunity to serve the TennCare program. Best Wishes, Joey Giamfortone Director, State Government Relations 1 Address Regulatory Barriers to Engaging Members As stated in the waiver, Tennessee’s block grant proposal is designed to allow the state the flexibility to pursue and promote core healthcare reform principles, such as member engagement, to allow members to become better healthcare consumers. Indeed, member engagement promotes healthcare consumerism, empowers enrollees, achieves better outcomes, improves quality measures and avoids and contains unnecessary costs. HMS currently conducts telephonic and SMS text based outreach to more than 20 million Medicaid and Medicare enrollees each year. Only consumers with a known relationship to Medicaid and/or Medicare who provide prior consent are contacted. Such outreach is intended to educate and engage consumers on their healthcare choices, remind consumers of ways to address their critical healthcare needs, improve quality and outcomes, and avoid unnecessary and improper healthcare spending. These may include calls to inform patients of steps to take during natural disasters and healthcare related recalls, as part of a vaccination outreach program, chronic disease management reminders and other reasons. The results are impressive as exemplified below.        12.5% year-over-year improvement in postpartum care rates, using HEDIS methodology 30% improvement in childhood vaccine administration 4.1% increase in well-child visit rate, using HEIDS methodology 10-13% increase in medication adherence 8.5% higher HbA1c testing rate for those who chose to receive communications in Spanish, 4.7% increase in HbA1c testing rates within 4 months 1.9% reduction in ER visits; $800,000 cost avoidance on behalf of one payer 2.2% reduction in 30-day, all-cause readmissions; 3.8 million cost avoidance Yet these wanted and effective engagements remain severely restricted by federal regulations, which in turn impairs TennCare’s ability to maximize member engagement as desired by the waiver. We urge TennCare to engage CMS on resolving the single largest barrier to member engagement, the Telephone Consumer Protection Act (TCPA) and its associated regulations. HMS stands at the ready to assist in this endeavor. Streamline Processes to Update Member Contact Information Applicants for TennCare provide a variety of contact information during the initial application and eligibility review process, including but not limited to their contact phone numbers, physical mail, and email addresses. TennCare and its contracted managed care organizations (MCOs) who may provide care to these applicants subsequently leverage this contact information for health care operations or clinical and quality improvement programs for the duration of the member’s eligibility period. However, member contact information is often wrong or outdated and results in low contact rates. Inaccurate, incomplete, or outdated contact information especially plagues the Medicaid population, which is often more transitory than the population as a whole. In fact, in our recent experiences, up to 60% of Medicaid enrollees who we reached with reminders of an upcoming renewal period reported they had not received their renewal paperwork in the mail. These types of unnecessary delays and hurdles can lead to lapses in care for particularly vulnerable populations. 2 There are several unnecessary programmatic and policy barriers that cause these issues that can be easily improved or eliminated to streamline processes to update enrollee contact information, which in turn can result in improved patient experience, higher quality care, and lower costs. First, we suggest that TennCare and its contracted MCOs provide simple, electronic means for enrollees to update their contact information throughout their enrollment, rather than having to go to a physical location to do so. We also recommend that enrollees be allowed to update their contact information directly with the MCOs that regularly have contact with and coordinate care more directly with the member (versus requiring that this occur through the state). In addition to streamlining enrollee processes, HMS encourages TennCare to leverage and authorize its contracted MCOs to ensure member contact information is up-to-date through third party sources that are widely available and utilized by other industries. Today, states and MCOs are reluctant to use third party sources due to the current understanding of implied consent, which applies only to contact information supplied in the application itself. This is particularly true of cell phone information, which is often the only reliable means of contact for members, and for which contact numbers can often change during a member’s enrollment in a program. As part of this waiver process, however, TennCare can update application instructions and disclosures to reflect that it and its MCOs are permitted to use other contact information that can be located for members, such as contact information that is provided by third party sources. Concerns for unwanted enrollee contact are mitigated since enrollees will maintain immediate opt-out rights, and the benefits of such communication and engagement outweigh any additional concerns. Implement a Medicaid Health Insurance Premium Payment Program Medicaid Health Insurance Premium Payment (HIPP) programs helps maintain Medicaid as payer of last resort by using federal and state funds to purchase employer sponsored insurance (ESI) for individuals and families otherwise eligible for Medicaid, if the cost of paying the premiums is less expensive than providing full Medicaid benefits. Support for HIPP has generally waxed and waned since established in the early 1990s. In recent years, advances in technology, changes to HIPP program requirements, and healthcare delivery and industry-wide reforms have made HIPP programs more appealing. In fact this year alone, at least nine states took strides toward establishing a new HIPP program or substantially expanding an existing program. We encourage TennCare to consider the use of HIPP to align with the waiver’s stated goal of consumer empowerment and choice. 3 Jonathan Reeve From: Sent: To: Subject: Attachments: jacy@thcc2.org Thursday, October 17, 2019 8:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Corrected: Amendment 42 Letter 191017 Corrected Response to Amendment 42 - Tennessee Health Care Campaign.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   There was a typo in the previously submitted letter. If possible please delete the previous email and attachment and use the attached. Sorry for the mix up. Thank you, Jacy --Jacy Warrell Executive Director Tennessee Health Care Campaign www.thcc2.org (615) 227-7500 ext. 8 (office) (270) 991-1103 (mobile)   1 October 18, 2019 Division of TennCare 310 Great Circle Road Nashville, TN 37243 RE: Amendment 42 –TennCare II Demonstration, Project No. 11-W-00151/4, “Block Grants” Mr. Roberts, Tennessee Health Care Campaign is writing in response to the Division of TennCare’s Amendment 42 draft waiver to change the financing structure for the TennCare program. As a nonprofit who works directly with TennCare beneficiaries and the uninsured, Tennessee Health Care Campaign is concerned that Amendment 42 makes promises that cannot be kept. Specifically, we are concerned that: • • • Amendment 42 offers no guarantee that Tennessee will opt to cover additional people or provide better services to improve the health of Tennesseans. The onus of reducing costs is on TennCare beneficiaries, rather than pharmaceutical companies, managed care organizations, and/or administering agencies. There will be insufficient oversight of any program changes. When Tennessee’s General Assembly passed legislation requiring the Division of TennCare to submit a “Block grant” waiver amendment, there was no discussion of using this waiver to provide coverage for additional people or provide additional benefits. There was no discussion of using this financing structure to address Tennessee’s most urgent health needs such as an increasing uninsured rate, access to care in rural communities, or addiction. In fact, no where is it written that the General Assembly, Governor’s Office, or the Division of TennCare are committed to improving the insured rate or improving specific health outcome measures for Medicaid eligible individuals. Tennessee is one of only 14 states that have chosen not to accept Medicaid Expansion dollars as allowed by the Patient Protection and Affordable Care Act. This denial of $1.2 Billion dollars annually can be directly linked to increased vulnerability of rural hospitals, higher infant mortality rates, higher chronic illnesses, and stunted ability to address mental health and addiction concerns. Tennessee’s General Assembly has established a well-documented opposition to adopting policies or models that work to improve health outcomes. Any proposal that does not include health coverage of individuals with income up to 138% of the Federal Poverty Level (FPL) shortchanges Tennessee. Amendment 42 repetitively references the claim that Tennessee operates one of the most cost-effective Medicaid programs in the nation. While this may be true by some measures, it is important to note that Tennessee does not offer the same level of coverage and services as other states. For example, Tennessee is one of only three states that does not provide any form of dental coverage for adults. The Division of TennCare references wanting to provide dental benefits for pregnant women, however CMS already allows states considerable flexibility in providing benefits in targeted populations such as this. According to the Division of TennCare in Amendment 42 draft waiver, Tennessee is spending less than the Centers for Medicare and Medicare Services (CMS) projects on an annual basis. Approving Amendment 42 rewards Tennessee for not providing benefits such as dental and could potentially incentivize other states to dropping dental coverage in the future. Tennessee Health Care Campaign understands and supports the idea that reducing costs is critical in the effort to sustain the Medicaid program and cover Tennessee’s working uninsured. As written, Amendment 42 focuses entirely on reducing costs in ways that will impact beneficiaries. In Tennessee there is no oversight of the Managed Care Organization (MCO) contracts and the contracts not publicly available. Amendment 42 should include a provision that MCOs have an appropriate Medical Loss Ratio. Shared savings should not go to greater profits and these contracts should be made publicly available as part of any comprehensive cost-savings effort. The onus of reducing costs should not rest on Tennessee’s most vulnerable people. In Tennessee Health Care Campaign’s experience working with TennCare eligible beneficiaries, we routinely encounter situations in which eligible families are denied coverage, approved families never receive their insurance card, and people unknowingly lose coverage. The request of Amendment 42 to reduce CMS oversight without outlining how Tennessee will provide clinical and administrative oversight has made beneficiaries and the community-based organizations that provide services to these families understandably nervous. When TennCare first transitioned to a Managed Care program, Tennessee Health Care Campaign served as an ombudsman to individuals who were eligible for Medicaid. This program was dissolved in 2005 when 170,000 adults were disenrolled because of a change in eligibility rules. Removing another level of oversight leaves Tennesseans more vulnerable and in the hands of state legislators who routinely attempt to tamper with the Medicaid program without regard to population health. Amendment 42 insufficiently explains how the Division of TennCare will legally maintain current eligibility and level of services in the event the Tennessee General Assembly decides to cut costs by changing eligibility or benefits. In conclusion, Tennessee Health Care Campaign is concerned that the Amendment 42 draft waiver makes promises that it cannot keep. This waiver gives Tennessee’s General Assembly an unprecedented amount of control over the health of children and families eligible for TennCare. It does not address how this waiver will address any of Tennessee’s pressing health problems such as in increasing uninsured rate. It appears to unfairly target eligible beneficiaries to reduce costs without attention to managed care organizations, pharmaceutical companies, or administrative costs. Respectfully, Jacy Warrell, MPA Executive Director Tennessee Health Care Campaign Tennessee Health Care Campaign •1423 Kensington Square Court, Murfreesboro, TN 37130 (615) 227-7500 • www.thcc2.org JAMES M. BECK, MD, ATSF President JUAN C. CELEDÓN, MD, DrPH, ATSF President-Elect POLLY E. PARSONS, MD, ATSF Immediate Past President LYNN M. SCHNAPP, MD, ATSF Vice President GREGORY P. DOWNEY, MD, ATSF Secretary-Treasurer KAREN J. COLLISHAW, MPP, CAE Executive Director October 18, 2019 Lisa Piercey, M.D., MBA, FAAP Commissioner Tennessee Dept. of Health 710 James Robertson Parkway Nashville, TN 37243 Dear Dr. Piercey: On behalf of the American Thoracic Society (ATS), thank you for the opportunity to comment on TN’s TennCare II demonstration proposal. The ATS is an international educational and scientific multi-disciplinary society of 16,000 members focused on respiratory, critical care and sleep medicine. The ATS supports the intent of the draft TennCare proposal to promote innovation, incentivize better health outcomes and reduce health system costs. We are pleased by the draft plan’s emphasis on promoting member health in addition to health care, including rural health transformation efforts in underserved areas of the state. We have the following comments: Financing While the ATS supports the intent of the TennCare proposal to reinvest savings the program may generate in member health, we have a number of substantial concerns about the risks posed by conversion of the program structure to a block grant and fiscal constraints such a structure will impose on the program. In addition, we are very concerned about the plan’s lack of specificity about individual policies aimed at reducing health costs and absence of a clear accountability structure to preserve member access to medically necessary care. Without more detail on specific cost reduction strategies that the state will use to reduce costs, it is difficult for us to evaluate the potential impact on member access to services and health outcomes and be confident that further negative impact on members will not occur. The challenging implementation of TN’s current 1115 waiver, which resulted in significant reductions in Medicaid coverage between 2016 and 2019, including an elimination of coverage for over 120,000 children, serves as a stark reminder of the potential impact of strategies that prioritize cost savings over coverage.i The ATS is deeply concerned that the current structure of the Tenncare block grant proposal may result in further losses of health coverage for more Tennessean’s, which will cause costly illness exacerbations. Page 2 We urge the state to maintain the Tenncare program as a traditional Medicaid program while utilizing the 1115 waiver process to promote program innovation, flexibility and health system savings without compromising member health. Prescription Drugs While we understand the state’s desire to implement prescription drug formulary management tools to guide coverage of costly new medications and devices, the ATS is concerned that by limiting coverage to potentially only a few prescription drugs per therapeutic class, perhaps even as few as only one drug per class, the plan may limit patient access to therapeutics rather than ensuring access to the range of drugs that best fit patient’s needs. Limits per drug class and category can present a problem for patients with respiratory diseases such as asthma, tuberculosis (TB) and for patients undergoing lung transplant. A common problem for patients with respiratory diseases including pneumonia and asthma is intolerance to some drugs, or a shortage of a drug, which requires an expeditious prescription change to another drug, often within the same class. The ATS urges the Department to ensure a transparent, streamlined and expeditious prior authorization process to permit approvals within 24 hours for alternate drugs not on the formulary’s list to ensure that patients and the public are not placed at risk for illness exacerbation and communicable disease transmission. Combination Therapies Patients with respiratory diseases such as cystic fibrosis, bronchiectasis, asthma, pulmonary arterial hypertension and TB may require various medications as part of combination therapy, which the draft plan does not address. We urge the Department to clarify that patients prescribed combination therapies will have full access to the medications they need. New Drugs We know that states must be judicious about the high costs of some new drugs, but we again urge the state to establish an expeditious and transparent system for ensuring access to medically necessary new therapeutics that have empiric evidence of clinical benefit to patients. These include new drugs for rare but life-limiting diseases such as cystic fibrosis and lung cancer, and biologics and nebulizers that can substantially improve disease management and prevent costly asthma and other respiratory exacerbations that can lead to critical illness and costly hospitalizations in addition to lost work productivity and school absences. The Department of Veteran’s Affairs Pharmacy and Therapeutics system provides a model system where new expensive drugs are quickly evaluated by price and efficacy with an expeditious approval process. Tobacco Cessation and Other Preventive Services The state of TN has a high prevalence of both smokers and individuals with lung cancer. Despite these disease burdens, the state currently has a comparatively low number of lung cancer screening programs relative to other states with similar burdens.ii Page 3 Open access to preventive tobacco cessation services will reduce the incidence and severity of chronic diseases associated with smoking, such as COPD and lung cancer and significantly reduces future health system costs. People trying to quit smoking may need to try several medications rather than just one. The ATS urges the Department to base tobacco cessation services on model benefit coverage provided by the Federal Employees Health Benefits Program (FEHB) and to clearly define all tobacco cessation benefits, including duration of therapy, in accordance with the 2008 U.S. Public Health Service guideline, Treating Tobacco Use and Dependence.iii The definition should include all tobacco cessation medications approved by the FDA, and individual, group and telephone counseling. To ensure full access for low-income TennCare members, tobacco cessation benefits must be provided without copays, deductibles or limits. The ATS urges the Department to ensure coverage of important preventive healthcare services recommended by the U.S. Preventive Services Task Force, such as lung cancer screening and tobacco cessation services, including overthe-counter (OTC) medications. Member Health Initiatives Although the ATS generally supports initiatives aimed at improving population health, such investments must be directed to both rural and urban areas with demonstrated need, including those with documented health disparities, to ensure health equity. We are concerned that a focus on population health, while a laudable goal, may come at the expense of reductions in coverage and medically necessary services for individuals. Fraud We are encouraged by the draft plan’s emphasis on the nature of underlying member Medicaid fraud offenses and consideration of alternatives to suspension or termination of health benefits, which indicate a willingness on the part of the state to work with individuals in this position, rather than simply penalize them and suspend or eliminate benefits in the long-term, which could cause adverse health outcomes, job loss and other serious life impacts. Graduate Medical Education State Medicaid program support is an important source of funding for graduate medical education (GME), which helps ensure the next generation of physicians to care for Tennesseans. The ATS is concerned that the draft proposal does not address whether and how Tenncare will continue to fund graduate medical education. We urge clarification on this important issue. Page 4 Provider Impacts The ATS urges the Department to ensure that the TennCare program does not create negative implications for Medicaid providers, including increased administrative requirements for frequent prior authorizations for medications and services and reduced provider reimbursement. It is critical that the state adopt measures to promote continued provider participation in the program to ensure access to care for Tennesseans. Thank you for the opportunity to comment. Sincerely, James Beck, M.D., ATSF President American Thoracic Society i Kelman, Brett. Tennessee Erased Insurance for at Least 128,000 Kids. Nashville Tennessean. 1 Apr 2019. https://www.tennessean.com/story/news/health/2019/04/02/tennessee-tenncare-coverkids-medicaid-erased-health-care-coverage-forchildren/3245116002/ ii Kale MS, Wisnivesky J, Taioli E, Liu B. The Landscape of US Lung Cancer Screening Services. Chest 2019; 155: 900-907. iii Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Rickville, MD: U.S. Department of Health and Human Services, U.S. Public Health Service; 2008. Jonathan Reeve From: Sent: To: Subject: Attachments: Jason Spain Wednesday, October 16, 2019 9:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on Draft Amendment 42 TC block grant letter.pdf     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Please see attached.      Thanks,    Jason Spain  Executive Director  Tennessee Public Transportation Association  (615) 347‐1528  jspain@tntransit.org    1 P.O. Box 210857 Nashville, TN 37221 (615) 347-1528 jspain@tntransit.org October 15, 2019 Mr. Gabe Roberts Director, Division of TennCare 310 Great Circle Road Nashville, TN 37243 Director Roberts: On behalf of the Board of Directors and members of the Tennessee Public Transportation Association (TPTA), I am writing to share our concerns regarding Draft Amendment 42, which would convert the federal share of Tennessee’s Medicaid funding to a block grant for most purposes. In a recently published op-ed summarizing the administration’s meetings with stakeholders to identify the most significant issues surrounding healthcare in Tennessee, Finance and Administration Commissioner Stuart McWhorter wrote, “transportation is a significant barrier to care. Lack of transportation keeps some Tennesseans from having access to a primary care physician or out-patient services. This inevitably leads to medical problems becoming unmanageable, requiring emergency transportation and services for conditions that could have been managed better.” We wholeheartedly agree with the commissioner’s point and fear that this amendment could represent a step in the wrong direction. While we applaud the administration’s stated goal of “no reductions in who is eligible for or what benefits are currently provided in TennCare,” (p.iii) our concern is that the state having the flexibility "to make changes to its benefits package, including the addition or elimination of optional benefits and changes in the amount, duration, and scope of covered benefits, without the need for CMS approval” (p.20) could lead to restrictions on or, should non-emergency medical transportation (NEMT) become an optional benefit as the Trump Administration has suggested, the elimination of NEMT in a flawed attempt to cut costs. As Commissioner McWhorter pointed out, Tennessee needs more transportation – not less. As you know, NEMT has been a mandatory Medicaid benefit by regulation since 1966, based on the premise that the program would be meaningless if patients were unable to get to and from their necessary medical appointments – that premise has not changed. Nationally, NEMT is utilized by only about 10 percent of Medicaid enrollees and accounts for only 1 percent of total Medicaid spending. Without this essential benefit, patients would be unable to access routine healthcare appointments as well as critical medical treatment, resulting in increased Medicaid expenditures for more expensive services. Tennessee’s 26 public transit agencies provided over 30 million trips last year in all 95 counties, including nearly 5.3 million in rural areas. They also provided 633,823 NEMT trips, or about 26% of all NEMT trips provided by TennCare in 2018. In addition to providing a critical service to those who in many cases have no other way to reach essential health care services, NEMT revenue is used to match federal transit funds to make public transportation in our rural areas possible. www.tntransit.org NEMT allows thousands of Tennesseans to access their primary care physicians and outpatient services, preventing the need for more costly emergency transportation and hospitalbased care. Restrictions on or the elimination of NEMT, as could be facilitated by this amendment, would have dire consequences for patients who rely on it to reach necessary medical care, particularly in rural areas where there simply are no other viable options. Thank you for your time and consideration. We appreciate the difficult task you face in providing the most effective care possible for enrollees while efficiently managing the states resources, and we look forward to continuing to be a partner in making sure that Tennesseans can access necessary medical care in the most efficient way possible. Please let me know if we can ever be of assistance in any way. Best regards, Jason Spain Executive Director Jonathan Reeve From: Sent: To: Subject: Attachments: TAAN Friday, October 18, 2019 10:38 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments Regarding TennCare Block Grant Proposal TennCare Draft Waiver Comments TAAN.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Hello please see comments from the Tennessee AIDS Advocacy Network regarding the proposed TennCare Block Grant. 1 October 18, 2019 Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 Dear Mr. Roberts: The Tennessee AIDS Advocacy Network (TAAN) appreciates the opportunity to comment on the draft of Tennessee’s TennCare II Demonstration Amendment 42 (the “Tennessee Draft Application”) under Section 1115 of the Social Security Act. TAAN is a non-partisan association of people affected by and concerned about HIV/AIDS in Tennessee. Our mission is to improve awareness among policymakers and the public about HIV/AIDS as a continuing public health priority within our state and the United States as a whole. Our goal is preservation, expansion and strengthening of the safety net of HIV prevention, care, treatment and support that addresses the needs of our fellow citizens at risk for or living with HIV and AIDS. The implications of Medicaid funding changes for people living with HIV should be particularly important to Tennessee. HIV disproportionately burdens the South, with over half of all new HIV diagnoses in the United States occurring in Southern states like Tennessee.1 As of 2017, over 17,000 people in Tennessee were living with HIV.2 Another 2,700 Tennesseans likely don’t even know they have HIV.3 The federal government has recognized the importance of addressing the HIV epidemic here. The Centers for Disease Control and Prevention has reported that Memphis has the 8th highest rate of new HIV diagnoses among U.S. cities.4 As a result, Memphis has been targeted in President Trump’s new campaign to reduce new HIV infections.5 Meanwhile, the epidemic continues to affect the lives of people living with HIV throughout Tennessee, and disproportionately affects our communities of color and LGBTQ individuals..6 1 HIV in the United States by Region, U.S. CTRS. FOR DISEASE CONTROL & PREVENTION (Sept. 9, 2019) https://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html (finding that in 2017, “[t]he South made up 52% (19,968) of all new HIV diagnoses in the US”). 2 HIV Surveillance Reports, TENN. DEP’T OF HEALTH, https://www.tn.gov/health/health-programareas/statistics/health-data/hiv-data.html (last visited Oct. 8, 2019). 3 H. Irene Hall et al., Prevalence of Diagnosed and Undiagnosed HIV Infection – United States, 2008–2012, 64 CTRS. FOR DISEASE CONTROL & PREVENTION MORBIDITY & MORTALITY WEEKLY RPT. 657, 660 (2015). 4 Nat’l Ctr. for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Ctrs. for Disease Control & Prevention, Diagnoses of HIV Infection in the United States and Dependent Areas, 2017, 29 HIV SURVEILLANCE REPORT 1, 122 (2017). 5 See Jessica Holley, Shelby County Awarded Millions in Federal Funding to Fight New HIV Infections, WMC5 ACTION NEWS (Jul. 31, 2019), https://www.wmcactionnews5.com/2019/07/31/shelby-county-awarded-millionsfederal-funding-fight-new-hiv-infections/. 6 See Local Data: Tennessee, AIDSVU, https://aidsvu.org/local-data/united-states/south/tennessee/ (last visited Oct. 8, 2019) (noting that 74.3% of people living with HIV are male, and that rates of African-American males and Medicaid is a critical source of health coverage for people living with HIV. Forty-two percent of adults living with HIV are covered by Medicaid, compared to just 13% of the general population.7 These individuals rely on the Medicaid program for the health care and treatment that keeps them healthy and productive. Ensuring uninterrupted access to effective HIV care and treatment is also important to public health goals. When HIV is effectively managed and individuals stay in treatment and virally suppressed, there is no risk of transmission.8 For the reasons discussed in detail below, we oppose the Tennessee Draft Application as written. Particularly, we believe that Tennessee should eliminate its proposals for a block grant and closed formulary. I. Tennessee should eliminate its proposal for a block grant. A. The Tennessee Draft Application’s proposal of capped funding is unlawful In the Draft Application, Tennessee proposes to convert federal Medicaid funding to a modified block grant structure. Under this proposal, the federal government would pay Tennessee a fixed amount of money as a block grant, based on the number of people enrolled in each eligibility category, and adjusted forward for inflation.9 Any savings accrued from Tennessee spending less than the block grant would be split equally between the federal government and the state.10 This proposal is not one that the Secretary of Health and Human Services (HHS) could lawfully approve, because it would require waiving Medicaid requirements that are not legally waivable. Medicaid’s funding mechanisms are outlined in Section 1903 of the Social Security Act, codified at 42 U.S.C. § 1396b. Section 1903 states that the HHS Secretary “shall pay to each State…the [federal match] of the total amount expended…as medical assistance under the State plan....”11 Despite Tennessee’s assertion that a block grant would not require waiving any specific provision,12 changing the funding mechanism would clearly violate this section. Therefore, it would require a waiver for federal approval. Section 1903, however, is not a waivable provision. Under Section 1115(a) of the Social Security Act, codified at 42 U.S.C. § 1315(a), the Secretary may waive certain requirements of Medicaid; namely, those found in sections 2, 402, 454, 1002, 1402, 1602, and 1902. If Congress had intended Section 1903 to be waivable as well, it would have listed it in the statute. The Centers for Medicare and Medicaid Services (CMS) itself has unambiguously stated that “Section females living with an HIV diagnosis are 6.3 and 13.7 times higher than that of white males and females, respectively). 7 Medicaid and HIV, KAISER FAMILY FOUND. (Oct. 1, 2019), https://www.kff.org/hivaids/fact-sheet/medicaid-andhiv/. 8 Eisinger RW, Dieffenbach CW, Fauci AS. HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable. JAMA. Published online January 10, 2019321(5):451–452. doi:10.1001/jama.2018.21167. 9 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 7–9 (2019). 10 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 10 (2019). 11 Social Security Act § 1903(a)(1), 42 U.S.C. § 1396b(a)(1) (2012). 12 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 22 (2019). 2 1115(a)(i) waiver authority extends only to provisions of section 1902 of the Act.”13 In 2018, CMS denied a Section 1115 waiver request that would have partially changed North Carolina’s federal matching rate by waiving Section 1905(b). In this denial, CMS acknowledged that it lacked the legal authority to change the Medicaid funding structure.14 The only legal way to construct Medicaid block grants or per capita caps is through a statutory change. Congress debated this kind of change in 2017,15 but ultimately decided not to pass it. HHS cannot accomplish through waivers something that the majority of Congress clearly did not intend to achieve. The HHS budget for fiscal year 2020 mentions legislative efforts to convert Medicaid to a block grant or per capita capped funding structure.16 This indicates that HHS is well aware of the fact that capped funding can only legally be accomplished by statutory change, not through a Section 1115 waiver.17 Secondly, HHS could not lawfully approve the Tennessee Draft Application because a capped funding structure would not promote the objectives of Medicaid. Section 1115(a) allows waivers for “any experimental, pilot, or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives” of Medicaid. The core objective of Medicaid, in the words of the Social Security Act, is “to furnish… medical assistance on behalf of families with dependent children and of aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services.”18 Multiple recent court decisions have repeatedly affirmed that “the ‘core’ objective of Medicaid [is] the provision of medical coverage to the needy.”19 In order to approve a Section 1115 demonstration, “the Secretary must address whether it creates a risk that beneficiaries will lose their Medicaid coverage.”20 The capped funding that Tennessee requests in its Draft Application creates such a risk. Block grant funding necessarily creates a risk of beneficiaries losing coverage. Under a block grant adjusted for medical inflation, Tennessee could expect to lose almost $2.4 billion over the next decade in federal Medicaid funding for children alone.21 Tennessee itself recognizes that a Letter from Seema Verma, Adm’r, U.S. Ctrs. for Medicare & Medicaid Servs., to Dave Richard, Deputy Sec’y for Medical Assistance, N.C. Dep’t of Health & Human Servs. (Oct. 19, 2018). 14 See Hannah Katch et al., Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grantproposal-threatens-care-for-medicaid-beneficiaries. 15 See, e.g., American Health Care Act of 2017, H.R. 1628, 115th Cong. § 121 (2017); Better Care Reconciliation Act of 2017, S. Amdt. 270 to H.R. 1628, 115th Cong. §§ 132–133 (2017); “Graham-Cassidy amendment,” S. Amdt. 1030 to H.R. 1628, 115th Cong. §§ 124–125 (2017). 16 See U.S. DEP’T OF HEALTH & HUMAN SERVS., PUTTING AMERICA’S HEALTH FIRST: FY 2020 PRESIDENT’S BUDGET FOR HHS, 69, 103 (2019). 17 See Letter from Frank Pallone, Jr., Chairman, U.S. House of Representatives Comm. on Energy & Commerce, to Alex M. Azar, Sec’y, U.S. Dep’t of Health & Human Servs. (Jun. 27, 2019). 18 Social Security Act § 1901, 42 U.S.C. § 1396 (2012). 19 Gresham v. Azar, 363 F. Supp 3d. 165, 181 (D.D.C. 2019); see also Stewart v. Azar, 313 F. Supp. 3d 237, 243 (D.D.C. 2018); Stewart v. Azar, 366 F. Supp. 3d 125, 138 (D.D.C. 2019); Philbrick v. Azar, No. 19-773, 2019 U.S. Dist. LEXIS 125678, at *24 (D.D.C. Jul. 29, 2019). 20 Philbrick v. Azar, No. 19-773, 2019 U.S. Dist. LEXIS 125678, at *25 (D.D.C. Jul. 29, 2019). 21 AVALERE HEALTH, MEDICAID BLOCK GRANTS AND PER CAPITA CAPS: PROJECTED IMPACT ON CHILDREN 8 (2019) (calculating an estimated loss of $2.39 billion in federal Medicaid funding for children from 2020 to 2029 under a block grant adjusted for medical inflation). 13 3 traditional block grant is financially risky.22 Tennessee suggests that it will mitigate this risk by increasing federal funding based on enrollment – essentially creating a per capita funding cap based on the projected costs per member used to calculate the block grant.23 Even with the Tennessee Draft Application’s proposed per capita cap, which promises “[n]o reductions in who is eligible for… TennCare,”24 gaps in coverage are likely. In fact, estimates show that a per capita cap would cost Tennessee even more in federal funding losses than a traditional block grant.25 Tennessee’s plan puts coverage at risk if per capita health costs increase faster than expected. The Tennessee Draft Application bases per capita cost increases on CBO projections,26 but there are a number of reasons why those projections might be drastically underestimated. Health care costs are difficult to estimate,27 and in several recent years, CBO has either significantly over-or under-estimated them even just a year in advance.28 In the past decade, health costs in the past decade have grown at historically low rates.29 It is still unclear whether these slowdowns are temporary or permanent, and we should not assume that increases will be this low in future years. Calculating Tennessee’s per capita inflation factor based on these projections could significantly underestimate the federal funding needed. Calculations based on regular market inflation would be even worse, since health care costs typically rise much faster than general economic inflation.30 Additionally, as the population ages, a larger portion of Tennessee Medicaid enrollees will be seniors and people with disabilities. Tennessee’s proposal to adjust the block grant based on enrollees in each category does not adequately address this shift, because population demographics are likely to shift within each category. As the “Baby Boomers” age, the population in Tennessee’s “elderly” category is likely to shift from people in their 60s and 70s to people in their 80s and 90s, who might incur Medicaid costs over 2.5 times higher.31 Because 22 DIVISION OF TENNCARE, TENNESSEE MEDICAID BLOCK GRANT PROPOSAL FREQUENTLY ASKED QUESTIONS 1 (2019). 23 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 9 (2019). 24 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 1 (2019). 25 See AVALERE HEALTH, MEDICAID BLOCK GRANTS AND PER CAPITA CAPS: PROJECTED IMPACT ON CHILDREN 10 (2019) (calculating an estimated loss of $2.55 billion in federal Medicaid funding for children from 2020 to 2029 under a per capita cap adjusted for medical inflation, compared to $2.39 billion for a block grant). 26 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 9 (2019). 27 See Jeanne M. Lambrew, Making Medicaid a Block Grant Program: An Analysis of the Implications of Past Proposals, 83 MILBANK QUARTERLY 41, 55–57 (2005) (finding less than 1/3 of growth in state and federal Medicaid costs explained by medical inflation, enrollment growth, and utilization changes combined). 28 See Edwin Park & Matt Broaddus, Medicaid Block Grant Would Shift Financial Risks and Costs to States, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 23, 2011), https://www.cbpp.org/research/medicaid-block-grantwould-shift-financial-risks-and-costs-to-states (showing variation between CBO estimates and actual costs in Figure 1). 29 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harmmillions-of (calculating that since 2010, CBO has lowered its projections for the 2011-2020 decade by 9.3 percent). 30 See Rabah Kamal & Cynthia Cox, How Has U.S. Spending on Healthcare Changed Over Time? PETERSONKAISER HEALTH SYSTEM TRACKER (Dec. 10, 2018), https://www.healthsystemtracker.org/chart-collection/u-sspending-healthcare-changed-time/. 31 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harm- 4 treatment has advanced such that HIV is a chronic condition and no longer a terminal diagnosis, people with HIV are living longer as well. People living with HIV are therefore encountering more health problems as they age. Other unexpected per capita cost increases might occur in response to a public health epidemic or a costly but lifesaving medical breakthrough.32 In any of these situations, the federal block grant funding would be insufficient and Tennessee would be left to bear all the unexpected costs. In response, it would not be surprising for Tennessee to drop coverage for beneficiaries who are most expensive to cover. These are likely to be individuals with disabilities or chronic diseases who need coverage most. Even if Tennessee does not directly cut eligibility, it could make it much harder for individuals to become or stay enrolled. The Tennessee Draft Application asks for “the flexibility to make changes to enrollment processes”33 without CMS approval. Among those changes could be requirements for enrollees to complete more paperwork or renew coverage more frequently, which have been shown to cause drops in enrollment even when eligibility rules remain the same.34 Tennessee already has a history of limiting enrollment.35 TennCare has closed enrollment36 and dropped people from coverage37 multiple times over its 25-year history. Most recently, TennCare his disenrolled 12% of children since 2016 by introduction of a new enrollment renewal millions-of (finding that “seniors aged 85 and older incurred average Medicaid costs in 2011 that were more than 2.5 times higher than those aged 65 to 74”) (emphasis in original). 32 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harmmillions-of; see also Edwin Park & Matt Broaddus, Medicaid Block Grant Would Shift Financial Risks and Costs to States, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 23, 2011), https://www.cbpp.org/research/medicaidblock-grant-would-shift-financial-risks-and-costs-to-states; Hannah Katch et al., Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grant-proposal-threatens-care-for-medicaid-beneficiaries. 33 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 19 (2019). 34 See MICHAEL PERRY ET AL., KAISER COMM’N ON MEDICAID & THE UNINSURED, MEDICAID AND CHILDREN OVERCOMING BARRIERS TO ENROLLMENT: FINDINGS FROM A NATIONAL SURVEY 8–14 (2000). 35 Hannah Katch et al., Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grantproposal-threatens-care-for-medicaid-beneficiaries. 36 See LEWIN GRP., OFFICE OF THE ASSISTANT SEC’Y FOR PLANNING & EVALUATION, ISSUES IN DEVELOPING PROGRAMS FOR UNINSURED CHILDREN: A RESOURCE BOOK FOR STATES app. A (1998), https://aspe.hhs.gov/report/issues-developing-programs-uninsured-children-resource-book-states/tenncare. 37 See Emily Siner, TennCare’s Big Cuts In 2005 May Have Delayed Breast Cancer Diagnoses, Study Suggests, NASHVILLE PUBLIC RADIO (Jun. 27, 2017), https://www.nashvillepublicradio.org/post/tenncare-s-big-cuts-2005may-have-delayed-breast-cancer-diagnoses-study-suggests; Brett Kelman, Tennessee Erased Insurance for at Least 128,000 Kids. Many Parents Don't Know, NASHVILLE TENNESSEAN (Apr. 4, 2019), https://www.tennessean.com/story/news/health/2019/04/02/tennessee-tenncare-coverkids-medicaid-erased-healthcare-coverage-for-children/3245116002/. 5 process.38 And currently, thousands of Tennesseans with intellectual or developmental disabilities remain on waiting lists for Medicaid waiver services.39 This proposed capped funding structure encourages Tennessee to limit coverage again if costs approach the federal funding cap – or even just to save money. The Tennessee Draft Application proposed funding structure creates an incentive for the state to spend as little as possible on Medicaid, so that it can receive “shared savings payments” along with the federal government. Tennessee’s promise of “state maintenance of effort,”40 assuring that it will contribute the same amount of state dollars as it typically has, is no guarantee. Tennessee is also requesting funding for “costs not otherwise matchable” to invest in services that would promote “health, not just healthcare.”41 Tennessee could easily demonstrate maintenance of effort by counting the amount of money it already spends on social services it believes support beneficiaries’ health, while at the same time reducing coverage.42 The capped funding structure proposed in the Tennessee Draft Application creates a substantial risk of coverage loss. Since capped funding is not “likely to assist in promoting the objectives”43 of Medicaid, HHS cannot approve this section of the waiver. If HHS were to approve this application, it would be arbitrarily and capriciously ignoring the objective of coverage, and this approval would be susceptible to vacatur by the federal courts. Finally, previous cases indicate that HHS could not justify approving the Tennessee Draft Application by arguing that the demonstration promotes alternative objectives of Medicaid. The D.C. District Court has held that beneficiary health and financial independence are not independently supportable objectives of Medicaid.44 Likewise, data collection for policymaking is not a Medicaid objective.45 Fiscal sustainability of the Medicaid program could be an objective, but must be weighed in the context of coverage.46 Therefore, while Tennessee has argued that their capped funding proposal “realign[s] incentives” to encourage economic savings for the federal government and the state,47 HHS must consider any such savings as secondary to the effects on health coverage. On balance, the risk to coverage clearly outweighs any resulting economic savings. 38 See Brett Kelman, Tennessee Erased Insurance for at Least 128,000 Kids. Many Parents Don't Know, NASHVILLE TENNESSEAN (Apr. 4, 2019), https://www.tennessean.com/story/news/health/2019/04/02/tennessee-tenncarecoverkids-medicaid-erased-health-care-coverage-for-children/3245116002/. 39 See, e.g., Tennessee, KIDS’ WAIVERS (Jan. 22, 2019), https://www.kidswaivers.org/tn/ (currently reporting 5813 people on waiting list); Tennessee Medicaid Waiver, MEDICAIDWAIVER.ORG, http://medicaidwaiver.org/state/tennessee.html (last visited Oct. 3, 2019) (currently reporting over 7000 people on waiting lists); Waiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waivers, KAISER FAMILY FOUND., https://www.kff.org/health-reform/state-indicator/waiting-lists-for-hcbs-waivers/ (last visited Oct. 3, 2019) (as of 2017 reporting 7248 people on waiting lists). 40 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 11 (2019). 41 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 13 (2019). 42 Hannah Katch et al., Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Sept. 25, 2019), https://www.cbpp.org/research/health/tennessee-block-grantproposal-threatens-care-for-medicaid-beneficiaries. 43 Social Security Act § 1115(a), 42 U.S.C. § 1315(a) (2012). 44 See Stewart v. Azar, 366 F. Supp. 3d 125, 143–148 (D.D.C. 2019). 45 See Philbrick v. Azar, No. 19-773, 2019 U.S. Dist. LEXIS 125678, at *46–47 (D.D.C. Jul. 29, 2019). 46 See Stewart v. Azar, 366 F. Supp. 3d 125, 148–155 (D.D.C. 2019). 47 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 10 (2019). 6 Some analysts have claimed that there is precedent for Medicaid block grants, because CMS has approved capped funding in states like Rhode Island and Vermont.48 But neither of these states actually received block grant funding. These comparisons misinterpret federal budget neutrality requirements. Longstanding CMS policy has been to only approve Section 1115 demonstrations that are expected to be budget neutral for the federal government; that is, that they “do[] not result in Medicaid costs to the federal government that are greater than what the federal government’s Medicaid costs would likely have been absent the demonstration.”49 The federal government will only match costs up to what is estimated without the waiver, and states are responsible for any overspending.50 TennCare, like all Section 1115 demonstrations, is already subject to this requirement.51 In Vermont’s Global Commitment to Health and Rhode Island’s Global Consumer Choice Compact, both states simply proposed to demonstrate budget neutrality based on aggregate costs, rather than per capita costs.52 This did not result in a block grant of funding.53 Both states noted that “[t]he standard Medicaid funding process shall be used during the demonstration.”54 The federal government still reimbursed the states based on FMAP. Additionally, both approvals allowed the states to opt out of the waiver at any time,55 in case federal contributions would be needed beyond the budget neutrality cap. Vermont and Rhode Island’s waivers are very different from the block grant that Tennessee is proposing now. In addition to the fact that they did not request block grant funding, Vermont and Rhode Island’s waivers were not even primarily concerned with federal funding. The overall 48 See, e.g., Rachana Pradhan & Dan Diamond, Trump wants to bypass Congress on Medicaid Plan, POLITICO (Jan. 11, 2019), https://www.politico.com/story/2019/01/11/trump-bypass-congress-medicaid-plan-1078885. 49 Letter from Timothy B. Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to State Medicaid Director. (Aug. 22, 2018). 50 See Letter from Timothy B. Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to State Medicaid Director. (Aug. 22, 2018). 51 See Centers for Medicare & Medicaid Services Special Terms and Conditions, No. 11-W-00151/4 (attachment to Letter from Acting Adm’r & Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to Gabe Roberts, Dir. of TennCare, Tenn. Dep’t of Fin. & Admin. (Jul. 2, 2019)). 52 See Centers for Medicare & Medicaid Services Special Terms and Conditions, Global Commitment to Health Section 1115 Demonstration, No. 11-W-00194/1; Centers for Medicare & Medicaid Services Special Terms and Conditions, Rhode Island Global Consumer Choice Compact Section 1115 Demonstration, No. 11-W-00242/1. See also, Letter from Timothy B. Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to State Medicaid Director. (Aug. 22, 2018). 53 See VT. AGENCY OF HUMAN SERVS., SUMMARY OVERVIEW: GLOBAL COMMITMENT TO HEALTH MEDICAID 1115 DEMONSTRATION WAIVER, (Nov. 3, 2005) (available at DEP’T OF VT. HEALTH ACCESS, https://dvha.vermont.gov/global-commitment-to-health/2005-global-commitment-to-health-documents) (“This is not a block grant.”); Edward Alan Miller et al., Medicaid Block Grants: Lessons from Rhode Island’s Global Waiver, STATE HEALTH ACCESS REFORM EVALUATION 3 (Jun. 2013) (“[T]he waiver does not stand as an example of an actual block grant.”). 54 Centers for Medicare & Medicaid Services Special Terms and Conditions, Global Commitment to Health Section 1115 Demonstration, No. 11-W-00194/1; see also, Centers for Medicare & Medicaid Services Special Terms and Conditions, Rhode Island Global Consumer Choice Compact Section 1115 Demonstration, No. 11-W-00242/1 (replacing “shall” with “must”). 55 See Centers for Medicare & Medicaid Services Special Terms and Conditions, Global Commitment to Health Section 1115 Demonstration, No. 11-W-00194/1; Centers for Medicare & Medicaid Services Special Terms and Conditions, Rhode Island Global Consumer Choice Compact Section 1115 Demonstration, No. 11-W-00242/1. 7 purpose of the waivers was to convert the state Medicaid system from fee-for-service to managed care,56 a change that Tennessee made long before.57 Neither Vermont nor Rhode Island was given the authority to curtail enrollment or benefits,58 and in fact both used the waivers to expand coverage and services.59 These waivers do not justify the unlawful capped funding structure that Tennessee is proposing. The Tennessee Draft Application’s block grant proposal is both unprecedented and not approvable under Section 1115. B. Capped funding creates risks for Tennessee and patients The Tennessee Draft Application’s proposed funding cap would create health risks for patients. As noted previously, as Tennessee approaches its federal funding cap, it might cut eligibility or make enrollment processes more difficult. These coverage gaps have serious health impacts for patients. Health coverage increases access to regular care and management,60 which is critical for patients with chronic illnesses like HIV.61 For individuals living with HIV, treatment disruptions can harm both individual and public health. Individuals that receive regular treatment and are virally suppressed cannot transmit HIV.62 Ensuring access to care, therefore, decreases downstream health care costs. Tennessee’s past enrollment cuts have already been shown to have detrimental effects. When TennCare dropped 170,000 people due to budget pressures in 2005, the loss in coverage was associated with a serious delay in diagnosing breast cancers.63 We could also expect cuts in benefits, affordability protections, or provider payments.64 Tennessee says that “it is not its intent under this proposal to reduce covered benefits for members below their current levels.”65 But CBO notes that one of the expected consequences of a funding cap is for states to restrict benefits, causing beneficiaries to pay out of pocket or forgo 56 See VT. AGENCY OF HUMAN SERVS., OFFICE OF VT. HEALTH ACCESS, VERMONT GLOBAL COMMITMENT TO HEALTH 6 (2005); Edward Alan Miller et al., Medicaid Block Grants: Lessons from Rhode Island’s Global Waiver, STATE HEALTH ACCESS REFORM EVALUATION 3 (Jun. 2013). 57 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 1 (2019). 58 See Foley Hoag, LLP, Tennessee Announces First-in-Nation Block Grant Proposal, JD SUPRA (Sept. 23, 2019), https://www.jdsupra.com/legalnews/tennessee-announces-first-in-nation-57656/. 59 See Judith Solomon & Jessica Schubel, “Block Grant” Guidance Will Likely Invite Medicaid Waivers That Pose Serious Risks to Beneficiaries, Providers, and States, CENTER FOR BUDGET AND POLICY PRIORITIES (Jun. 27, 2019), https://www.cbpp.org/research/health/block-grant-guidance-will-likely-invite-medicaid-waivers-that-pose-seriousrisks-to. 60 See Benjamin D. Sommers et al., Health Insurance Coverage and Health — What the Recent Evidence Tells Us, 377 NEW ENG. J. MED. 586 (2017). 61 See, e.g., Brian W. Ward, Barriers to Health Care for Adults with Multiple Chronic Conditions: United States, 2012–2015, 275 NAT’L CTR. H. STATISTICS DATA BRIEF 1 (2017). 62 See Robert W. Eisinger et al., HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable. 321 JAMA 451, 451 (2019). 63 Wafa W. Tarazi et al., Impact of Medicaid Disenrollment in Tennessee on Breast Cancer Stage at Diagnosis and Treatment, 123 CANCER 3312, 3316–3317 (2017). 64 See Rachel Sachs & Nicole Huberfield, The Problematic Law And Policy Of Medicaid Block Grants, HEALTH AFFAIRS (July 24, 2019), https://www.healthaffairs.org/do/10.1377/hblog20190722.62519/full/; Judith Solomon & Jessica Schubel, “Block Grant” Guidance Will Likely Invite Medicaid Waivers That Pose Serious Risks to Beneficiaries, Providers, and States, CENTER FOR BUDGET AND POLICY PRIORITIES (Jun. 27, 2019), https://www.cbpp.org/research/health/block-grant-guidance-will-likely-invite-medicaid-waivers-that-pose-seriousrisks-to. 65 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 16 (2019). 8 services entirely.66 Tennessee has already demonstrated its willingness to cut (or at least threaten to cut) benefits due to budget concerns, as recently as this year. 67 Eight times since 2010, Tennessee has attempted to reduce benefits in order to address an anticipated budget shortfall in the fiscal year. 68 Each year, Tennessee submitted a TennCare amendment seeking to limit or eliminate coverage of selected services for TennCare eligible adults.69 Each amendment was subsequently withdrawn because the legislature reauthorized a private hospital fee reauthorization.70 Still, the threat of curtailing benefits is very real, and would be exacerbated by capped federal funding. Many people with chronic illnesses like HIV depend on the benefits provided by Medicaid, and it is inappropriate to “play chicken” with their healthcare. It also would be reasonable to expect that Tennessee might impose premiums, deductibles, or increased co-pays, all or which would discourage enrollment and access to care.71 Tennessee also might reduce payments to provider and managed care plans. The Tennessee Draft Application already requests enhanced flexibilities with respect to compensating hospitals72 and negotiating with managed care programs.73 If these flexibilities include payment cuts, it could make providers less willing to accept Medicaid patients and cause managed care plans to “shrink their provider networks, curtail quality assurance, or drop out of the program altogether.”74 Already, some rural Tennessee providers are unwilling to accept TennCare patients because of low reimbursement rates. As a result, people living with HIV already have to travel long distances to see their providers. Cutting TennCare state funding would exacerbate the problems we already face with patients being uninsured, having trouble finding providers, and having to travel long distances to obtain care.75 Capped federal funding also creates severe economic risks for Tennessee. Losing the federal entitlement buffer is dangerous for states. Currently, uncapped Medicaid serves as a 66 See Establish Caps on Federal Spending for Medicaid, U.S. CONG. BUDGET OFFICE (Dec. 13, 2018), https://www.cbo.gov/budget-options/2018/54726. 67 See Letter from Gabe Roberts, Dir., TennCare, to Judith Cash, Dir., State Demonstrations Grp., U.S. Ctrs. for Medicare & Medicaid Servs. (Apr. 15, 2019) (requesting Amendment 39); Letter from Gabe Roberts, Dir., TennCare, to Judith Cash, Dir., State Demonstrations Grp., U.S. Ctrs. for Medicare & Medicaid Servs. (May 29, 2019) (withdrawing Amendment 39). 68 See Letter from Gabe Roberts, Dir., TennCare, to Judith Cash, Dir., State Demonstrations Grp., U.S. Ctrs. for Medicare & Medicaid Servs. (Apr. 15, 2019) (requesting Amendment 39). 69 See, e.g., Letter from Darin J. Gordon, Dir., Bureau of TennCare, to Eliot Fishman, Dir., Family & Children’s Health Programs Grp., U.S. Ctrs. for Medicare & Medicaid Servs. (Jan. 27, 2014) (requesting Amendment 21). 70 See TennCare II Section 1115 Demonstration Fact Sheet (Feb. 2, 2016) (found at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/?entry=8387). 71 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harmmillions-of. 72 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 16 (2019). 73 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 19 (2019). 74 Establish Caps on Federal Spending for Medicaid, U.S. CONG. BUDGET OFFICE (Dec. 13, 2018), https://www.cbo.gov/budget-options/2018/54726. 75 See Edwin Park, Medicaid Per Capita Cap Would Shift Costs and Risks to States and Harm Millions of Beneficiaries, CENTER FOR BUDGET AND POLICY PRIORITIES (Feb. 27, 2017), https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-shift-costs-and-risks-to-states-and-harmmillions-of. 9 “countercyclical source of federal funds for states during economic downturns.”76 Without the possibility of federal funding to respond to an economic downturn, public health crisis, or entry of a new blockbuster drug, 77 Tennessee would have to shoulder all unexpected costs. Puerto Rico, which receives modified block grant Medicaid funding, has struggled to respond to increased health needs and provider shortages after Hurricanes Irma and Maria.78 Additionally, a state requesting the first Section 1115 waiver for block grant funding would have to expect an expensive legal challenge. For example, Kentucky’s Section 1115 application for work requirements was submitted in August 2016, and now has only reached the D.C. Circuit Court of Appeals in October 2019. If Tennessee proposes a block grant, it would have to be prepared drawn-out litigation, causing uncertainty for Tennessee citizens about the future of their healthcare. For all of these reasons, the Tennessee Draft Application’s proposal of a capped funding structure is neither lawful nor a beneficial approach for Tennessee and its citizens. II. Tennessee should eliminate its proposal for a closed formulary. A. The Tennessee Draft Application’s proposed waiver of formulary requirements is unlawful Tennessee proposes that in exchange for accepting capped federal funding, it be given the flexibility to adopt a commercial-style closed formulary.79 However, HHS could not lawfully approve this proposal, since formulary requirements are not waivable. The Medicaid Drug Rebate Program requires all drug manufacturers to provide rebates to the state and federal government as a condition of having their drugs covered on Medicaid. The program reduces state and federal spending, while still ensuring that Medicaid beneficiaries can access the drugs they need.80 Formulary requirements for states in the Medicaid Drug Rebate Program are outlined in Section 1927 of the Social Security Act, codified at 42 U.S.C. § 1396r-8. As with Section 1903 on funding, Section 1927 is not found in the list of waivable provisions under Section 1115 authority.81 The D.C. Circuit has confirmed that Section 1115 “does not 76 Establish Caps on Federal Spending for Medicaid, U.S. CONG. BUDGET OFFICE (Dec. 13, 2018), https://www.cbo.gov/budget-options/2018/54726. 77 See Judith Solomon & Jessica Schubel, “Block Grant” Guidance Will Likely Invite Medicaid Waivers That Pose Serious Risks to Beneficiaries, Providers, and States, CENTER FOR BUDGET AND POLICY PRIORITIES (Jun. 27, 2019), https://www.cbpp.org/research/health/block-grant-guidance-will-likely-invite-medicaid-waivers-that-pose-seriousrisks-to. 78 See Judith Solomon, Puerto Rico’s Medicaid Program Needs an Ongoing Commitment of Federal Funds, CENTER FOR BUDGET AND POLICY PRIORITIES (Apr. 22, 2019), https://www.cbpp.org/research/health/puerto-ricos-medicaidprogram-needs-an-ongoing-commitment-of-federal-funds. 79 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 13–14 (2019). 80 See Edwin Park, Ctr. for Children & Families, Geo. Univ. Health Policy Inst., How to Strengthen the Medicaid Drug Rebate Program to Address Rising Medicaid Prescription Drug Costs, 5 THE FUTURE OF CHILDREN’S HEALTH COVERAGE 1, 1 (2019). 81 Social Security Act § 1115(a)(1), 42 U.S.C. § 1315(a) (2012). 10 authorize [the Secretary] to waive any requirements of section 1396r–8’s rebate provision.”82 In 2018, CMS also affirmed that Section 1927 is not waivable by rejecting Massachusetts’ Section 1115 proposal to create a closed formulary.83 CMS said that the only way for to implement a closed formulary would be to opt out of Section 1927 entirely, then “the state would have to negotiate directly with manufacturers and forgo all manufacturer rebates available under the federal Medicaid Drug Rebate Program.”84 Tennessee tries to sidestep the problem by proposing to waive Section 1927 indirectly. Section 1902(a)(54) of the Social Security Act requires that if a state provides coverage for outpatient prescription drugs, it must comply with the requirements of Section 1927.85 Tennessee is seeking to waive Section 1902(a)(54) insofar as it incorporates Section 1927.86 But Tennessee cannot use Section 1902(a)(54) as a loophole when Congress clearly did not enumerate Section 1927 as a waivable provision. Attempting to waive all of the requirements of Section 1927 clearly goes beyond the bounds of the Secretary’s authority under Section 1115. And this strategy is not likely to be successful – it is the same waiver of Section 1902(a)(54) that Massachusetts already proposed and CMS rejected.87 Furthermore, Tennessee has not demonstrated that a closed formulary would be an appropriate demonstration project. In order to qualify for a Section 1115 waiver, the proposal must be an “experimental, pilot, or demonstration project.” Tennessee’s justification for a closed formulary, like that of Massachusetts’ failed proposal, is purely economic. Federal courts have explained that an economic justification is not enough. “The Secretary’s obligation under § [1115] to ‘make some judgment that the project has a research or a demonstration value’ cannot be satisfied by ‘[a] simple benefits cut, which might save money, but has no research or experimental goal.’”88 Additionally, a closed formulary would not promote the goals of Medicaid. As previously noted, the primary objective of Medicaid is to “furnish medical assistance to…citizens.”89 A closed formulary restricts the scope of assistance that is provided to Tennessee citizens. Even if a closed formulary would help Medicaid be more fiscally sustainable (which, as explained below, may not be true), economic savings would have to be weighed in the context of coverage.90 A closed formulary restricts patient benefits and could lead to disenrollment for individuals who find that their necessary medications are not covered. On balance, HHS would not be able to approve this proposal. 82 PhRMA v. Thompson, 251 F.3d 219, 222 (D.C. Cir. 2001). See Letter from Tim Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs. U.S. Ctrs. for Medicare & Medicaid Servs., to Daniel Tsai, Assistant Sec’y, MassHealth, Exec. Office of Health & Human Servs. (Jun. 27, 2018). 84 Letter from Tim Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs. U.S. Ctrs. for Medicare & Medicaid Servs., to Daniel Tsai, Assistant Sec’y, MassHealth, Exec. Office of Health & Human Servs. (Jun. 27, 2018). 85 Social Security Act § 1902(a)(54), 42 U.S.C. § 1396a(a)(54) (2012). 86 See DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 22 (2019). 87 See Letter from Tim Hill, Acting Dir., Ctr. for Medicaid & CHIP Servs., U.S. Ctrs. for Medicare & Medicaid Servs., to Daniel Tsai, Assistant Sec’y, MassHealth, Exec. Office of Health & Human Servs. (Jun. 27, 2018). 88 Newton-Nations v. Betlach, 660 F.3d 370, 381 (9th Cir. 2011) (citing Beno v. Shalala, 30 F.3d 1057, 1069 (9th Cir. 1994)). 89 Stewart v. Azar, 313 F. Supp. 3d 237, 243 (D.D.C. 2018). 90 See Stewart v. Azar, 366 F. Supp. 3d 125, 155 (D.D.C. 2019); 83 11 B. A closed formulary will negatively impact Tennessee and its residents Closing formularies is not a smart economic decision for a state Medicaid program. The Tennessee Draft Application proposes that it be able to “use the same tools as Medicare and commercial payers to lower drug costs.”91 But this comparison neglects important differences between Medicaid and other prescription drug coverage plans. Individuals enrolling in commercial plans or Medicare Part D have the freedom to choose a specific plan that provides the medications they need. But on Medicaid, individuals have only one plan option; most are on Medicaid because they by definition have no other choice for insurance coverage. Medicaid beneficiaries also have higher rates of chronic disease than people not on Medicaid.92 People with chronic illnesses like HIV need the flexibility of an open formulary to optimally manage their conditions. Even if Medicare were an adequate comparison, it does not enact the harsh formulary restrictions that Tennessee proposes here. Medicare Part D formularies must include at least two drugs per therapeutic category.93 CMS can require more drugs for a particularly category or class “if additional drugs present unique and important therapeutic advantages in terms of safety and efficacy, and their absence from the sponsor’s formulary would substantially discourage enrollment by beneficiaries with certain disease states.”94 Tennessee’s proposal does not adopt any such safeguards to protect the flexibility needed by patients with chronic illnesses. Nor does it include an appeals process for beneficiaries with a medical need for drugs that aren’t covered. The Medicaid Drug Rebate Program already saves states more money than commercial plans or Medicare Part D. In 2016, pharmaceutical manufacturers paid $31.2 billion in rebates to Medicaid, lowering drug costs by 51.3%.95 In contrast, in the same year, rebates negotiated by private insurers for Medicare Part D only lowered costs by 19.9%.96 Estimates indicate that Medicaid generally receives rebates of 61% off the retail price for brand-name drugs, whereas Medicare Part D only negotiates rebates to about 31% and private insurance plans achieve rebates of only 16%.97 Additionally, CBO reported that for top-selling, brand-name specialty 91 DIVISION OF TENNCARE, TENNCARE II DEMONSTRATION AMENDMENT 42 DRAFT 13 (2019). See Laura Joszt, Identifying the Most Prevalent and Costly Chronic Conditions in Medicaid, AM. J. MANAGED CARE (Nov. 28, 2017), https://www.ajmc.com/newsroom/identifying-the-most-prevalent-and-costly-chronicconditions-in-medicaid. 93 42 C.F.R. § 423.120(b)(2) (2019). 94 See U.S. CTRS. FOR MEDICARE & MEDICAID SERVS., MEDICARE PRESCRIPTION DRUG BENEFIT MANUAL, 30.2.1 (Jan. 15, 2016). 95 Edwin Park, Ctr. for Children & Families, Geo. Univ. Health Policy Inst., How to Strengthen the Medicaid Drug Rebate Program to Address Rising Medicaid Prescription Drug Costs, 5 THE FUTURE OF CHILDREN’S HEALTH COVERAGE 1, 2 (2019). 96 BDS. OF TRS., FED. HOSP. INS. & FED. SUPPLEMENTARY MED. INS. TR. FUNDS, THE 2018 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS 143 (2018). 97 CHARLES ROEHRIG, ALTARUM, THE IMPACT OF PRESCRIPTION DRUG REBATES ON HEALTH PLANS AND CONSUMERS 2 (2018). 92 12 drugs, “the average price per prescription was nearly twice as high in Medicare Part D as in Medicaid” after rebates.98 Further, a closed formulary will not produce the cost savings that Tennessee expects. Systematic reviews analyzing over 90 studies have shown that formulary restrictions have either a negative effect or no effect on pharmacy and medical costs.99 Saving money in the short-term by restricting access to necessary medications only serves to increase costs in the long-term by necessitating avoidable follow-up care for worsening conditions. Also, TennCare already has leverage to negotiate with pharmaceutical manufacturers through a preferred drug list.100 Additional leverage through a closed formulary is both unnecessary and unproductive. Most importantly, closed formularies negatively impact individual health. Formulary restrictions have been associated with lower medication adherence101 and poorer health outcomes in general.102 A fully closed formulary, like the Tennessee Draft Application proposes, would have even more severe effects. A closed formulary would be particularly harmful for individuals with chronic and complex conditions. For example, decreases in medication utilization due to closed formularies are even more severe for patients with chronic illness.103 Problems with HIV medication adherence can increase the risk of drug resistance, making a patient’s drug regimen ineffective.104 In managing HIV, physicians express a need to tailor individual therapy for 98 ANNA ANDERSON-COOK ET AL., HEALTH, RETIREMENT, AND LONG-TERM ANALYSIS DIVISION, U.S. CONG. BUDGET OFFICE, PRICES FOR AND SPENDING ON SPECIALTY DRUGS IN MEDICARE PART D AND MEDICAID 5 (2018) (available at U.S. CONG. BUDGET OFFICE, https://www.cbo.gov/system/files/115th-congress-2017-2018/ presentation/53929presentation.pdf) (calculating that for the top 50 brand-name specialty drugs in Medicare Part D in 2015, average cost after rebates was $3,600 in Medicare Part D versus $1,920 in Medicaid). 99 Yujin Park et al., The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systematic Literature Review, 23 J. MANAGED CARE & SPECIALTY PHARM. 893, 898 (2017) (reviewing 59 unique studies and observing that the majority of “studies that included total or medical costs (in addition to pharmacy costs)… showed either negative effect on total, medical, or pharmacy costs or no effect on pharmacy costs”); Laura E. Happe et al., A Systematic Literature Review Assessing the Directional Impact of Managed Care Formulary Restrictions on Medication Adherence, Clinical Outcomes, Economic Outcomes, and Health Care Resource Utilization, 20 J. MANAGED CARE & SPECIALTY PHARM. 677, 681 (2014) (reviewing 93 studies and concluding “there was no distinct trend in the direction of association of economic outcomes with formulary restrictions”). 101 See Laura E. Happe et al., A Systematic Literature Review Assessing the Directional Impact of Managed Care Formulary Restrictions on Medication Adherence, Clinical Outcomes, Economic Outcomes, and Health Care Resource Utilization, 20 J. MANAGED CARE & SPECIALTY PHARM. 677, 681 (2014); Seth A. Seabury et al., Formulary Restrictions on Atypical Antipsychotics: Impact on Costs for Patients with Schizophrenia and Bipolar Disorder in Medicaid 20 AM. J. MANAGED CARE e52, e58 (2014). 102 See Yujin Park et al., The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systematic Literature Review, 23 J. MANAGED CARE & SPECIALTY PHARM. 893, 898 (2017); Seth A. Seabury et al., Formulary Restrictions on Atypical Antipsychotics: Impact on Costs for Patients with Schizophrenia and Bipolar Disorder in Medicaid 20 AM. J. MANAGED CARE e52, e58 (2014). 103 See Brenda R. Motheral & Rochelle Henderson, The Effect of a Closed Formulary on Prescription Drug Use and Costs, 36 INQUIRY 481, 485 (1999-2000). 104 See Drug Resistance, AIDS INFO (Jan. 28, 2019), https://aidsinfo.nih.gov/understanding-hiv-aids/factsheets/21/56/drug-resistance. 13 patients105 by trying multiple drugs in the same therapeutic class. For these patients, less restrictive formulary designs yield better outcomes and reduce costs.106 Blocking access to necessary drugs is dangerous for patients and will not produce the economic benefits Tennessee seems to expect. For these reasons, Tennessee should eliminate its proposal for a closed formulary from its Section 1115 waiver application. Conclusion Tennessee’s proposals to cap federal Medicaid funding and restrict the TennCare formulary are both improper under Section 1115 and unwise. But Tennessee does have a readily available alternative to save money: Medicaid expansion. Tennessee is forfeiting an estimated $26.1 billion over the next decade by refusing to expand Medicaid.107 Medicaid expansion would bring in more federal funding and reduce the costs of uncompensated care. With less uncompensated care, hospitals have more stability108 and cost-sharing can be lowered for people with insurance.109 Further, evidence has already shown that Medicaid expansion leads to better health outcomes, access, and affordability.110 In states that expanded Medicaid, HIV testing increased,111 allowing for earlier detection, treatment, and prevention. In expansion states, fewer people with HIV are uninsured,112 which is also linked to a lower likelihood of death in the 105 See Formulary Decision-Making Challenges in HIV, AM. J. MANAGED CARE (March 19, 2018), https://www.ajmc.com/peer-exchange/special-considerations-in-hiv-management/formulary-decisionmakingchallenges-in-hiv. 106 See James Baumgardner et al., Modeling the Impacts of Restrictive Formularies on Patients With HIV, 24 AM. J. MANAGED CARE (SPECIAL ISSUE NO. 8) SP322, SP325 (2018). 107 Louise Norris, Tennessee and the ACA’s Medicaid Expansion, HEALTHINSURANCE.ORG (Sept. 18, 2019), https://www.healthinsurance.org/tennessee-medicaid/. 108 See Richard C. Lindrooth et al., Understanding The Relationship Between Medicaid Expansions And Hospital Closures, 37 HEALTH AFFAIRS 111 (2018) (finding that states that did not expand Medicaid had a higher rate of hospital closures). 109 See Hayes McAlister, Moving the Needle for Medicaid Expansion in Tennessee Pt. 1, TENN, JUSTICE CTR. (Jul. 7, 2019), https://www.tnjustice.org/medicaid-expansion-tennessee-important-moving-the-needle/. 110 See Robin Rudowitz & Larisa Antonisse, Implications of the ACA Medicaid Expansion: A Look at the Data and Evidence, KAISER FAMILY FOUND. (May 23, 2018), https://www.kff.org/medicaid/issue-brief/implications-of-theaca-medicaid-expansion-a-look-at-the-data-and-evidence/. 111 See Yunwei Gai & John Marthinsen, Medicaid Expansion, HIV Testing, and HIV-Related Risk Behaviors in the United States, 2010–2017, 109 AM. J. PUBLIC HEALTH 1404, 1407 (2019) (finding a 3.22% increase in HIV test rates for Medicaid expansion states compared to non-expansion states). 112 See Medicaid’s Role for Individuals with HIV, KAISER FAMILY FOUND. (Apr. 18, 2017) https://www.kff.org/infographic/medicaids-role-for-individuals-with-hiv/ (finding that in expansion states, the percentage of uninsured individuals with HIV in care decreased from 14% in 2012 to 7% in 2014). 14 hospital.113 Expanding Medicaid is also an easy political choice – almost two-thirds of Tennesseans support Medicaid expansion.114 TAAN thanks you for the opportunity to comment on the Tennessee Draft Application. For all of the reasons discussed above, we strongly urge Tennessee to eliminate its proposals for capped funding and a closed formulary. Yours Truly, Jasper Hendricks Jasper L. Hendricks, III Director, Tennessee AIDS Advocacy Network ________________________________________________ d: 615-259-4866 ext. 301 c: 615-788-4587 f: 615-467-1004 633 Thompson Lane Nashville, TN 37204 113 Fred J. Hellinger, In Four ACA Expansion States, the Percentage of Uninsured Hospitalizations for People With HIV Declined, 2012–14, 34 HEALTH AFFAIRS 2061 (2015) (finding that in four expansion states, hospitalizations of uninsured patients with HIV fell from 13.7% to 5.5%, while in two nonexpansion states, hospitalizations of uninsured patients with HIV increased from 14.5% to 15.7%; and finding that patients with HIV who were uninsured were 40% more likely to die in the hospital). 114 Andy Humbles, Poll: 63 Percent Support Medicaid Expansion in Tennessee, NASHVILLE TENNESSEAN (May 7, 2018), https://www.tennessean.com/story/news/2018/05/07/medicaid-expansion-poll-tennessee-support/586006002/ (reporting 63% of registered voters supporting Medicaid expansion, and only 21% opposing). 15 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Natalie Kean Friday, October 18, 2019 3:09 PM PUBLICE NOTICE TENNCARE Jennifer Goldberg; Amber Christ [EXTERNAL] Justice in Aging Comments on Proposed Amendment 42 to TennCare II Demo Justice in Aging Comments on Proposed Amendment 42 to TennCare II Demo.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you for consideration of Justice in Aging’s attached feedback on Amendment 42.     Natalie Kean  Pronouns: she, her, hers  Senior Staff Attorney, Justice in Aging  Office: (202) 621‐1038   nkean@justiceinaging.org    Twitter: @justiceinaging    Watch our new video: In Their Own Voices: How Lifelong Discrimination Leads to Poverty Among Older  Women…and join us to take action.       1 October 18, 2019 Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Submitted via e-mail: public.notice.tenncare@tn.gov Re: Amendment 42 to TennCare II Demonstration Justice in Aging appreciates the opportunity to comment on the state’s proposed Amendment 42 to the TennCare II Demonstration under section 1115 of the Social Security Act. For the reasons discussed below, we strongly oppose the proposal which would convert “the bulk of TennCare’s federal funding to a block grant” and urge the state to withdraw it. Justice in Aging is an advocacy organization with the mission of improving the lives of low-income older Tennesseans and older adults nationwide. We use the power of law to fight senior poverty by securing access to affordable health care, economic security and the courts for older adults with limited resources, particularly populations that have traditionally lacked legal protection such as women, people of color, LGBTQ individuals, and people with limited English proficiency. We have decades of experience with Medicare and Medicaid and have worked extensively with advocates who represent low-income older Tennesseans. Justice in Aging conducts trainings and engages in advocacy regarding Medicare and Medicaid, provides technical assistance to attorneys in Tennessee and across the country on how to address problems that arise under these programs, and advocates for strong consumer protections at both the state and federal level. We urge the state to withdraw this proposal because of the harms it would cause to Tennesseans who rely on Medicaid to access health care and long-term services and supports. Capping funding fundamentally alters the Medicaid program and does not allow it to fulfill its objective of providing health coverage to those who cannot otherwise afford it. Cutting or artificially limiting the “bulk” of federal funding (or funding for any part of the program) will directly harm the populations the state intends to include under the block grant, most especially people with disabilities and older adults who have higher health care needs. It will also inhibit TennCare’s capacity to serve older adults and people with disabilities not included in the block grant, especially as needs increase with the unprecedented growth of the older adult population1 and the simultaneous increases in senior poverty.2 Our comments address our opposition to the waiver amendment as not promoting the objectives of the Medicaid program and harming older adults, as well as specific concerns we have with how the proposed amendment is designed. The Proposed Waiver Amendment Would Fail to Promote the Medicaid Program’s Objectives. Under federal law, Medicaid demonstration waivers cannot be used to alter the basic funding structure.3 Implementing a block grant would radically change the funding structure and therefore the program. “Reconceiving the partnership between the state and federal government” as the draft proposal states is simply not permissible. Furthermore, federal law provides that such waivers are allowed only if they are “likely to assist in promoting the objectives” of the Medicaid program.4 The Amendment 42 proposal fails to meet this standard. Medicaid’s primary objective is to furnish medical assistance to low-income persons.5 Yet the draft does not address how block granting the bulk of the program will advance providing coverage to Tennesseans who cannot otherwise afford coverage. In fact, as discussed more fully below, capping funding would actually lead to cuts in coverage and therefore undermine Medicaid’s main objective. Much of the draft’s discussion of the purpose of the Amendment is around saving the state money, which is not an objective of the Medicaid program. Moreover, there are no guardrails to ensure that any potential “savings” from cutting federal funding through a block grant would be used to provide coverage to low-income Tennesseans. Capping Federal Medicaid Funding will Harm Older Adults Capping federal Medicaid funding to the state cannot be accomplished without harming Tennesseans who rely on TennCare currently or may one day need TennCare. Unlike the existing funding structure that responds to need by guaranteeing a federal match for every dollar the state spends, a block grant will artificially limit the federal contribution and make it impossible for TennCare to fully respond to future needs, both those that are expected and unexpected. Because the state cannot go into debt to cover growing needs of its TennCare population, it will be forced to cut services, restrict eligibility, or 1 By 2030, nearly 1 in 5 Tennesseans will be age 65 or older. Univ. of Virginia Weldon Cooper Ctr. for Public Service, Observed & Projected Population Proportion at 65+ for the U.S. and the States, 2010-2040, https://demographics.coopercenter.org/national-population-projections. 2 Justice in Aging, Senior Poverty, https://www.justiceinaging.org/senior-poverty/ 3 42 U.S.C. 1315(a) specifies which requirements can be waived. The list does not include 42 U.S.C. 1392b, which governs financing of Medicaid. 4 42 U.S.C. 1315(a) 5 See 42 U.S.C. § 1396-1; Memorandum Opinion, Stewart v. Azar, Civil Action No. 1:18-cv-152 (JEB), filed June 29, 2018. 2 both.6 So while the state may be attempting to carve out individuals dually eligible for Medicare and Medicaid, and therefore the vast majority of seniors and many people with disabilities, from the capped funding, these populations cannot be carved out from the harm that will result when TennCare can no longer afford to provide coverage and services to its entire Medicaid population. We disagree with the state’s assertion that the block grant is not expected to have a material impact on enrollment. While the proposal itself may have few provisions directly addressing eligibility, capped funding and growing needs will necessitate limiting eligibility in the future across the program. There is no guarantee that these inevitable restrictions on eligibility will not impact populations the state is asserting are exempt from the proposed block grant. In fact, because dually eligible populations utilize more care and require higher spending, restricting eligibility for these populations would be the easiest way to make up for funding shortfalls from the block grant. In addition, even if the state chooses to make cuts not directly aimed at older adults and people with disabilities, such cuts will affect both access and quality of care for all TennCare enrollees. For example, if the state decreases provider payment rates or is unable to increase them, fewer providers will accept TennCare, which means decreased access for all enrollees.7 Concerns about the Block Grant’s Design and Its Impact on People Dually Eligible for Medicare & Medicaid We have serious concerns about how the waiver is designed and how both the state intends it to impact older adults and people dually eligible for Medicare and Medicaid, as well as how it will actually impact this population. The proposal says that “Expenditures on behalf of individuals who are enrolled in Medicare, including cost sharing and premium assistance (including Medicare Part D “claw back” payments) paid on behalf of individuals who are dually enrolled in Medicare and TennCare” are not included in the block grant. This language does not make clear whether all people who are dually eligible for Medicaid and Medicare, including those who are eligible for full Medicaid benefits, are excluded. It could be read to only exclude so-called “partial duals” who are eligible for the Medicare Savings Programs but not for any other Medicaid benefits. Adding to the confusion is the fact that the block grant is calculated using 64,679 “elderly” member months for the base period enrollment. While the proposal says this number excludes “Medicare members,” we question that it excludes all dually eligible adults age 65 and older. Multiple data sources show both nationwide and in Tennessee specifically, nearly all seniors are enrolled in Medicare as are an even higher percentage of seniors who are enrolled in Medicaid. For example, the Census Bureau’s American Community Survey data shows that in 2018, there were 138,000 individuals dually in Medicare and Medicaid in Tennessee who were age 65+. There were also 138,000 Medicaid 6 Justice in Aging, Medicaid Funding Caps Would Harm Older Americans (Feb. 2017), https://www.justiceinaging.org/wpcontent/uploads/2017/02/Medicaid-Funding-Caps-Would-Harm-OlderAmericans.pdf?eType=EmailBlastContent&eId=443776c8-cb7a-4c89-991a-85ede6f99509. 7 Id. 3 enrollees age 65+ in Tennessee. This aligns with the Kaiser Family Foundation’s data for 2013: 99% of Tennessee Medicaid enrollees age 65+ that year were dually enrolled in Medicare.8 In other words, it is not clear who is included in this “elderly” number being used to calculate the base block grant amount. It seems unlikely that it truly excludes all 65+ persons who are also enrolled in Medicare. Furthermore, the enrollment number the state provides for the “disabled” category does not indicate that it excludes “Medicare members,” which it should if the state is intending to exclude all persons dually eligible for Medicare and Medicaid. In fact, the majority of people dually eligible are under age 65. We have similar questions about whether all individuals enrolled in any of the state’s 1915(c) waivers or only individuals with intellectual disabilities are excluded. The draft amendment uses different language at various points to describe the 1915(c) populations that it is intending to carve out. Given these apparent inconsistencies and lack of clarity as to which populations are included in the block grant and which are carved out, we are fearful that the state has not fully thought through the impacts of its proposal. We question how excluding all duals would work given that some categories such as home and community based services are delivered to both dually eligible and non-dually eligible populations. It seems impractical if not impossible to have different funding mechanisms for the same Medicaid eligibility pathway based on whether someone is dually eligible for Medicare. We are concerned that the state does not fully understand the probable impact of capped funding on every single TennCare population. This alone is reason that the state should withdraw the proposal. However, if the state does choose to move forward, it must clarify whether it is excluding all dually eligible beneficiaries, regardless of age or type of Medicaid coverage and ensure that the numbers it is using for its base calculation are accurate. Conclusion For these reasons, we urge the state to withdraw this proposal and focus on improving and expanding coverage for low-income Tennesseans, including older adults and people with disabilities. If any questions arise concerning this submission, please contact Natalie Kean, Senior Staff Attorney, at nkean@justiceinaging.org. Sincerely, Jennifer Goldberg Deputy Director 8 Aged and Disabled Dual Eligibles as a Percent of Total Medicaid Beneficiaries, https://www.kff.org/medicaid/stateindicator/ageddisabled-medicaidbeneficiaries/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 4 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Jennifer McMullen Friday, October 18, 2019 2:57 PM PUBLICE NOTICE TENNCARE Anna Richardson [EXTERNAL] Block Grant comment submission - DaVita, Inc. TennCare Block Grant Comments 101619.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please find attached comments regarding the Tenncare Medicaid Block Grant and the impact to ESRD patients.    Thank you for your consideration,   Jennifer      Jennifer McMullen  Director, State Government Affairs  Davita, Inc.    CONFIDENTIALITY NOTICE: THIS MESSAGE IS CONFIDENTIAL, INTENDED FOR THE NAMED RECIPIENT(S) AND MAY  CONTAIN INFORMATION THAT IS (I) PROPRIETARY TO THE SENDER, AND/OR, (II) PRIVILEGED, CONFIDENTIAL, AND/OR  OTHERWISE EXEMPT FROM DISCLOSURE UNDER APPLICABLE STATE AND FEDERAL LAW, INCLUDING, BUT NOT LIMITED  TO, PRIVACY STANDARDS IMPOSED PURSUANT TO THE FEDERAL HEALTH INSURANCE PORTABILITY AND  ACCOUNTABILITY ACT OF 1996 ("HIPAA"). IF YOU ARE NOT THE INTENDED RECIPIENT, OR THE EMPLOYEE OR AGENT  RESPONSIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY  DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU HAVE  RECEIVED THIS TRANSMISSION IN ERROR, PLEASE (I) NOTIFY US IMMEDIATELY BY REPLY E‐MAIL OR BY TELEPHONE AT  (855.472.9822), (II) REMOVE IT FROM YOUR SYSTEM, AND (III) DESTROY THE ORIGINAL TRANSMISSION AND ITS  ATTACHMENTS WITHOUT READING OR SAVING THEM. THANK YOU.   ‐DaVita Inc‐  1 DaVita, Inc. 2000 16th Street Denver, CO 80202     [TYPE TEXT]  [TYPE TEXT]  [TYPE TEXT]    VIA ELECTRONIC SUBMISSION (Public.notice.tenncare@tn.gov) October 18, 2019 Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: Amendment 42 to the TennCare II Demonstration, Project No. 11-W-00151/4 Dear Mr. Roberts: DaVita Inc. (“DaVita”) appreciates the opportunity to submit comments in response to Amendment 42 (the “Amendment”) to the TennCare II Demonstration. DaVita is a dialysis provider that strives to provide quality life-saving medical care to patients diagnosed with end stage renal disease (“ESRD”). DaVita owns or operates approximately 2,650 outpatient clinics nationwide, 66 of which are located in Tennessee. DaVita is proud to be a participating provider in the TennCare health care program. As a participating provider, DaVita serves approximately 249 TennCare beneficiaries. These beneficiaries, like all of DaVita’s patients, suffer from a serious chronic illness, often accompanied by numerous comorbidities, and require significant medical care. Generally, ESRD patients require three dialysis treatments every week in addition to numerous prescription drugs, labs, and other care. Because of this, DaVita wishes to make certain comments designed to ensure any change in the TennCare program does not negatively impact quality care that is required for ESRD patients. I. Consider high cost of ESRD patients in grant proposal calculation The Amendment’s block grant calculation does not appear to contemplate the impact of high cost patients generally, or ESRD beneficiaries specifically, in the program’s total costs. DaVita recommends that TennCare specifically consider the costs of treating chronically ill patients, especially those with ESRD disease, in its block grant calculation. As noted in the Amendment Proposal, the block grant would be calculated by determining the cost per patient in four different categories: (1) blind and disabled, (2) elderly, (3) children, and (4) adults. The     2000 16th Street, Denver, CO 80202 P (303) 876‐2868     DaVita.com     stated purpose of dividing the patient population into these four categories is that they have “a history of different expenditure patterns or cost profiles and thus, pose differing levels of risk to the state.” However, unless the expenditures for each category would be capped by the calculated amount (which does not appear to be the case), then the purpose of the four categories is unclear. In other words, it is unclear if there is a difference between (1) calculating the block grant through the four categories, and (2) averaging per patient costs across all beneficiaries. The reason for this concern is that it is unclear how or whether high-cost beneficiaries with chronic illnesses impact this calculation. Theoretically, ESRD patients can be, and are, included in every one of the four stated categories. For purposes of this block grant calculation, it is unclear whether an ESRD patient would fall into the blind and disabled category, or fit into a different category based solely on age. It is important to consider ESRD patients and other similar high-cost patient categories because TennCare gauges the level of risk that each type of beneficiary poses to the state. High-cost, chronically ill patients represent a level of risk unlike the four categories in the Amendment Proposal. TennCare does not discuss how it addresses each level of risk in its actuarial process. In order to ensure that high cost patients are properly accounted for, we recommend specifying how ESRD patients will be categorized and how each group’s risk factor will be contemplated in the block grant calculation. II. Increase transparency for proposed action when costs exceed proposed block grant DaVita seeks greater transparency regarding how TennCare proposes to handle projected costs exceeding the block grant amount. While the proposed block grant is indexed for inflation and for enrollment growth beyond the enrollment figures reflected in the base period, the proposal is vague about how TennCare would handle per member costs exceeding the projected block amount as a result of extenuating circumstances—including, for example, an unusually high increase in the number of new ESRD patients. The Amendment specifically states that there will be “no reductions in who is eligible for or what benefits are currently provided in TennCare.” While this is an encouraging statement, it is unclear what measures would be taken if costs exceeded the block grant amount. It was not clear how or whether new beneficiary enrollments were considered in the block grant calculation, and how those new enrollments may impact the cost model. For example, new ESRD patients typically generate higher costs due to initial 2  2000 16th Street, Denver, CO 80202   P (303) 876‐2868 DaVita.com     training and care. Medicare accounts for these additional costs by adding an “onset” payment to dialysis providers for the 120 days after the start of a patient’s chronic renal dialysis. Here, it is unclear whether this cost impact was considered and, if costs exceeded the grant amount, whether this would result in a reduction in services or a decrease in rates that would trickle down from the MCOs to the providers. Potential negative impact to ESRD beneficiaries is particularly concerning, given the chronic nature of the disease and the level of care required. Any disruption in treatment for an ESRD patient can be extremely harmful given that life-sustaining medical care is required on a daily or almost-daily basis. The fiscal note accompanying the Amendment concludes that “officials cannot estimate [the Amendment’s] impact on people, federal funding, or the state’s economy.” The fact that TennCare has articulated that the impact to beneficiaries is unknown adds to our concerns, and we are therefore searching for greater clarity regarding specific potential impact to ESRD beneficiaries. III. Clarify the meaning of “delivering the right care to the right members” Under the proposal, the State would have the flexibility to vary benefits packages for different members based on medical factors or other considerations. Specifically, the Amendment states that Tennessee intends to “better focus delivery of benefits” or “marshal resources to respond to specific health needs, so that members receive the care most relevant for their needs while the state is able to maximize the use of its available funding.” DaVita has concerns that the proposal may lead to less comprehensive coverage for ESRD patients, who by definition, require extensive resources for very specific health needs. Responding to the needs of ESRD patients would by no means “maximize” use of available funding. While the Amendment indicates that TennCare’s intent is not to reduce covered benefits for members, any actual reduction or change in the way benefits are managed or delivered could negatively impact ESRD patients. It is also concerning that the State proposes to have the ability to make changes to its benefits package, including the addition or elimination of optional benefits and changes in the amount, duration and scope of covered benefits, without the need for CMS approval. The Amendment states that the proposal does not confer new authority on the State because it is already “the states’ prerogative to elect to cover or not cover optional benefits.” Notwithstanding, it is worrisome that the State seeks to potentially eliminate optional benefits (and it is unclear what those optional benefits may be or whether the State would have the 3  2000 16th Street, Denver, CO 80202   P (303) 876‐2868 DaVita.com     flexibility to change what may be considered to be an optional benefit) that may be critical to certain patient groups. DaVita seeks additional information regarding optional benefits that could be eliminated and what groups they would impact most. IV. Address impact to providers DaVita requests additional detail and clarity from TennCare regarding the Amendment’s potential impact to providers, particularly from a rate perspective. DaVita is concerned that the block grant proposal could lead to Tennessee cutting reimbursements to health care providers. As TennCare is 100% managed care, we recognize that this would theoretically involve a reduction in the capitated rate to its contracted MCOs. However, such a reduction would likely trickle down to the in-network and out-of-network providers submitting claims. Such potential cuts could negatively impact provider enrollment and the quality of needed care provided to TennCare beneficiaries. V. Conclusion DaVita respectfully requests that TennCare consider the impact that the Amendment will have on ESRD patients. Specifically, we ask that you (1) consider high cost patients, and ESRD patients specifically, in the program’s grant proposal calculation; (2) increase transparency around how TennCare proposes to address projected costs exceeding the block grant amount; (3) clarify (a) the State’s ability to vary benefits packages for different members based on medical factors, as well as (b) what the optional benefits include and how they may change; and (4) address the specific potential impact to providers who may be impacted by any reduction in capitated rates to TennCare’s contracted MCOs. ESRD patients are a highly vulnerable group who would be deeply affected by any reduction in services, and we feel strongly that protecting their interests is of utmost importance. We appreciate your consideration of our comments and welcome the opportunity to discuss our concerns. Sincerely, Jennifer McMullen Director, State Government Affairs DaVita, Inc. Jennifer.mcmullen@davita.com 4  2000 16th Street, Denver, CO 80202   P (303) 876‐2868 DaVita.com Jonathan Reeve From: Sent: To: Subject: Attachments: Franklin, Karen Friday, October 18, 2019 12:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] NASW, Tennessee Chapter Letter on Amendment 2 NASW-TNLetteronTennCareAmendment2.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you for considering the attached letter related to Amendment 2.    Karen L. Franklin, LAPSW  Executive Director  NASW, Tennessee Chapter  50 Vantage Way, Suite 250  Nashville, TN 37228‐1554  Phone: (615) 321‐5095  Toll‐free: (877) 810‐8103  Kfranklin.naswtn@socialworkers.org        Visit www.naswtn.com to learn more about our on‐going activities and the social work profession in Tennessee.         1 Jonathan Reeve From: Sent: To: Subject: Attachments: Mullins, Kelly Thursday, October 17, 2019 9:09 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Pfizer's 1115 waiver comments TennCareIIDemoWaiverAmendment42_10162019.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Director Roberts,    Please find our attached comments in response to the 1115 waiver amendment. We are very grateful for the  opportunity to be a part of the process.    Best,    Kelly    Kelly Mullins  Government Relations Director – TN, KY & WV  Pfizer Inc.  C: (615) 992‐8959  kelly.mullins@pfizer.com      1 Pfizer Inc 235 East 42nd Street New York, NY 10017 Tel: 615-992-8959 Email: kelly.mullins@pfizer.com Kelly Mullins Director, Government Relations October 15, 2019 VIA ELECTRONIC DELIVERY Mr. Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: Comments of Pfizer, Inc. Regarding TennCare II Demonstration Waiver Amendment 42 Dear Director Roberts, Pfizer, Inc. (“Pfizer”) appreciates this opportunity to comment on the recently submitted TennCare II Section 1115 Demonstration Waiver Amendment 42. Pfizer is committed to saving and improving lives through the development of medicines and vaccines, applying the latest science and technology to meet the most demanding healthcare challenges of today. Pfizer appreciates Tennessee’s exploration of financial stability in its Medicaid program. However, the request to waive Section 1902(a)(54) of the Social Security act, specifically Medicaid drug formulary requirements of Section 1927(d)(4) would jeopardize the ability of Medicaid beneficiaries to access life-saving therapies. Additionally, Pfizer supports and agrees with additional issues raised by other commenters, including the Pharmaceutical Research and Manufacturers of America (“PhRMA”) and the Biotechnology Innovation Organization (“BIO”). Pfizer is particularly concerned by the state’s proposal to “have the flexibility under this demonstration to adopt a commercial-style closed formulary with at least one drug available per therapeutic class.”1 The Centers for Medicare and Medicaid Services (CMS) has already reviewed and rejected a similar attempt by Massachusetts to restrict patient access to certain medicines in 2018. Additionally, this proposal fails to meet certain basic requirements for Medicaid waivers under Social 1 TennCare II Demonstration Waiver Amendment 42 proposal, September 2019. 1 Security Act (“SSA”) section 1115,2 and does not align with Congressional intent underlying the Medicaid rebate statute.3 Further, the proposed formulary exclusions would block the neediest patients from accessing cutting-edge care that the patient and his or her physician has selected as medically necessary and that the FDA has approved as safe and effective. I. Tennessee’s Proposal Fails to Satisfy the Requirements for Section 1115 Waivers. The states proposal is contrary to the opinion rendered in PhRMA v. Thompson, in which the D.C. Circuit held that SSA section 1115 does not authorize waivers of the Medicaid rebate statute.4 Second, such a waiver would destroy an essential element of the legislative compromise codified by Congress in the Medicaid rebate statute. Under the rebate statute, manufacturers of innovator drugs pay deep rebates to Medicaid programs, in exchange for Medicaid beneficiaries receiving the drug coverage protections described in Section III of these comments. For innovator drugs, the statute provides Medicaid programs with a price net of the rebate that is at least as low as the manufacturer’s best price to any commercial customer. Many cases have held that when a statute reflects such a legislative compromise, the interpretation of the law should uphold the compromise.5 States can negotiate supplemental rebates above what is statutorily mandated; making the argument dubious that states can negotiate better rebates by opting out of the statute. Tennessee’s proposal would fall short of section 1115 waiver requirements in other significant ways and represents a benefit cut, which is not a permissible subject for a section 1115 waiver.6 The 2017 proposal by Massachusetts to use a closed formulary with at least one drug per class and with the intent to exclude drugs approved through the FDA’s accelerated approval process was firmly rejected by CMS. A state cannot simply opt out of §1927 and not provide access to “covered outpatient drugs” for which a manufacturer has a signed National Rebate Agreement.7 The same day of CMS’ letter to Massachusetts, the agency issued “State Release No. 185,” which underscored the fact that drugs approved through the FDA’s expedited approval processes “must be covered by state Medicaid programs, if the drug meets the definition of “covered outpatient drug” as found in Section 1927 of the Social Security Act”8 and the Manufacturer has a signed Medicaid National Rebate agreement. II. Tennessee’s Proposal Would Jeopardize Access for the Neediest Patients and Block Coverage of Cutting-Edge Treatments for Life-Threatening Conditions. Tennessee’s waiver amendment also indicates the state would exclude new innovative drugs approved through the FDA accelerated approval process “from its formulary until market prices are consistent with prudent fiscal administration or the state determines that sufficient data exists 2 Codified at 42 U.S.C. § 1315. Codified at 42 U.S.C. § 1396r-8. 4 251 F.3d 219, 222 (D.C. Cir. 2001) (“Although the Act authorizes the Secretary to waive certain Medicaid requirements for such demonstration projects, it does not authorize him to waive any requirements of section 1396r–8’s [the Medicaid rebate statute’s] rebate provision or the requirement that Medicaid beneficiaries contribute no more than a ‘nominal’ amount to the cost of medical benefits they receive.”). 5 See, e.g., General Motors Corp. v. Romein, 503 U.S. 181, 191 (1992) (upholding statutory provisions necessary to “preserve [] the delicate legislative compromise that had been struck by [prior] laws”). 6 Beno v. Shalala, 30 F.3d 1057, 1069 (9th Cir. 1994) (“[Section 1115] requires that the state project be an ‘experimental, demonstration or pilot’ project. The statute was not enacted to enable states to save money or to evade federal requirements but to ‘test out new ideas and ways of dealing with the problems of public welfare recipients.’”). 7 CMS letter to Asst. Secretary Tsai, MassHealth, June 27, 2018. 8 CMS State Release No. 185, June 27, 2018. 3 2 regarding the cost of effectiveness of the drug.”9 We believe that this language is an attempt to target for exclusion drugs that enter the market through the FDA’s accelerated approval pathway.10 The federal Food, Drug, and Cosmetic Act (FDCA) authorizes the FDA to approve a product that treats “a serious or life-threatening disease or condition . . . upon a determination that the product has an effect on a surrogate endpoint that is reasonably likely to predict clinical benefit . . . taking into account the severity, rarity, or prevalence of the condition and the availability or lack of alternative treatments.”11 Medicines approved through the accelerated pathway are those that the FDA has determined meet the key requirements of safety and efficacy, and that the FDA believes should be approved on an expedited basis because they are needed to treat “serious and life-threatening” diseases and conditions. The FDA explains in its guidance that the accelerated approval process requires “that the effect be shown, in the judgement of the agency, clinically meaningful, and of such importance as to outweigh the risks of treatment. This judgment does not represent either a ‘lower standard’ or one inconsistent with section 505(d) of the act [i.e., FDA criteria for refusing applications, including the “substantial evidence” standard].” 12 Existing literature supports this characterization. Researchers at Tufts University, for example, found that drugs cleared through FDA’s expedited review process “offered larger health gains, compared to drugs approved through conventional review processes.”13 The FDA is the expert agency for determining products’ safety and efficacy, including those receiving accelerated approvals. U.S. law does not require a demonstration of “incremental benefit” for product approval. Instead, drugs are approved if they are “safe and effective,” whether the drug receives approval under the traditional or the accelerated pathway. Tennessee should not reject coverage for products used for their FDAapproved indications. If the waiver were implemented as is, thousands of TennCare beneficiaries would lose access to treatments for severe and life-threatening conditions. One such drug is Ibrance® (palbociclib), a CDK 4/6 inhibitor, the first drug of its class approved for patients with HR+/HER2- metastatic breast cancer in combination with endocrine therapy. Ibrance was granted accelerated approval in February 2015 for the treatment of HR-positive, HER2-negative advanced or metastatic breast cancer in combination with an aromatase inhibitor as initial endocrine based therapy in postmenopausal women and then received regular approval—first in February 2016 (in combination with fulvestrant in women with disease progression following endocrine therapy), and then in March 2017 (in combination with an aromatase inhibitor as initial endocrine based therapy in postmenopausal women).14 In that span of two years, over 60,000 women in the United States received Ibrance® treatment, a drug granted priority review and designated as a “breakthrough therapy”15 by the FDA. Providing access to a wide variety of drug agents remains the cornerstone to improved patient care as one formulary agent may not produce the intended therapeutic outcome across all patient types. Also, side effect profiles vary across all patient types and a closed formulary design may lead to 9 TennCare II Demonstration Waiver Amendment 42 proposal, September 2019 Id. at 9 (“Many drugs coming to market through the FDA’s accelerated approval pathway have not yet demonstrated clinical benefit and have been studied in clinical trials using only surrogate endpoints.”). 11 21 U.S.C. § 356. 12 FDA, “New Drug, Antibiotic, and Biological Drug Product Regulations; Accelerated Approval,” 57 Fed. Reg. 58942, 58944 (Dec. 11, 1992). 13 Chambers et al., “Drugs Cleared Through the FDA’s Expedited Review Offer Greater Gains Than Drugs Approved by Conventional Process,” 36 Health Affairs 1408-1415 (Aug. 2017), http://content.healthaffairs.org/content/36/8/1408.full. 14 See FDA, “Palbociclib (IBRANCE)” (updated March 31, 2017), https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm549978.htm. 15 Id. 10 3 therapy discontinuation due to side effects. These concerns are even more heightened as science and innovation moves toward personalized medicine, particularly in rare and chronic diseases. III. Tennessee should Use Existing Tools to Control Cost and Ensure Access. Tennessee should evaluate the use of cost-containment tools it already possesses under current law. Under the Medicaid rebate statute, states may exclude drugs from a Medicaid formulary that are not used for medically accepted indications—if these key requirements are all met: (1) the drug does not “have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome” over a drug on the formulary; (2) the state provides a publicly-available written explanation of the basis for the exclusion; (3) the excluded drug is available using prior authorization; and (4) the formulary is developed by a committee of medical experts that meets the composition requirements specified under the statute.16 Importantly, under the rebate statute a “medically accepted indication” means “any use . . . which is approved” by the FDA (or which is supported by one or more compendia listings).17 The state can also seek flexibility to negotiate voluntary alternative payment models based on outcomes or amortized payment contracts to assist in demonstrating positive outcomes and continued access to innovative products for beneficiaries. Pfizer appreciates Tennessee’s movement toward innovative coverage for beneficiaries, however, such innovation should not violate section 1115 or block patient access to cutting edge therapies. To that end, Tennessee should use its existing tools to explore additional strategies. Pfizer offers to be a partner with Tennessee in exploring these options. If I can be of any assistance, please do not hesitate to contact me at 615-992-8959 or at kelly.mullins@pfizer.com. Sincerely, Kelly Mullins Director, Government Relations Tennessee Kentucky West Virginia 16 17 42 U.S.C. § 1396r-8(d)(2). 42 U.S.C. § 1396r-8(k)(6). 4 Jonathan Reeve From: Sent: To: Subject: Attachments: Kristen Dinger Tuesday, October 15, 2019 10:01 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments regarding TennCare Waiver Amendment 42 Public Comment TNCare Block Grant with attachments.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***         Kristen Keely‐Dinger, LAPSW  President & CEO  2928 Sidco Drive, Nashville, TN  37204  615‐284‐8271 ext 115  www.healingtrust.org   Twitter    LinkedIn   Facebook  YouTube Website    1 POLICY BRIEF September 19, 2019 BREAKING DOWN TENNCARE’S BLOCK GRANT PROPOSAL TennCare has released a draft of its opening bid in negotiations with federal regulators over a Medicaid block grant. (1) The proposal includes three key components: 1. A broad set of administrative and benefit design flexibilities that Tennessee could tap without prior federal approval or oversight. 2. An allotment to replace current federal funding for a portion of TennCare costs. 3. The opportunity to keep (without a state match requirement) half of any savings from spending less than the full allotment. This brief asks (and attempts to answer) seven questions to help stakeholders understand the details of the proposal and what it could mean for TennCare enrollees and providers and the state’s budget. Editor’s Note: This post is based on our initial analysis of the draft as released on 9/17/2019. Should we receive clarifying information on any piece of our interpretation, we will update the post accordingly. KEY TAKEAWAYS • The plan would give Tennessee policymakers unprecedented control over changes to optional program benefits and provider payments without federal approval or oversight. • The state would also shoulder some additional long-term financial risk under this plan, but overall the proposed funding changes are weighted heavily in Tennessee’s favor. • This broad shift in power from federal to state policymakers could have significant effects on TennCare spending, enrollees, and providers — either positive, negative, or mixed depending on if and how current or future state officials use that power. 1. Why is TennCare proposing this? Earlier this year, the General Assembly passed legislation requiring TennCare submit a request to the federal government to convert the state’s Medicaid funding into a block grant. It established a November deadline for submission to the federal Centers for Medicare and Medicaid Services (CMS) and included broad parameters for how the block grant should work. (2) 2. What flexibilities are in the proposal? The draft waiver proposes a broad set of benefit design and administrative flexibilities that Tennessee could tap without prior federal approval or oversight. Federal approval processes are largely in place to ensure transparency, set goals and parameters, and evaluate and monitor the effects of changes on enrollees. (3) (4) (5) However, these processes can also be administratively burdensome for states. (4) Any use of the new flexibilities — either administratively or through legislation — would be defined exclusively by the state without having to conform to existing federal approval and reporting processes. The Sycamore Institute SycamoreInstituteTN.org POLICY BRIEF Breaking Down TennCare’s Block Grant Proposal TennCare’s proposed flexibilities fit into three buckets. 1. The draft proposes to tap existing flexibilities to change benefits — but without the formal federal oversight and approval currently required. For example, TennCare would like the ability to modify both the coverage of optional benefits and details of other covered benefits (e.g. how much is covered and for how long) without federal approval. Other examples include tailoring benefits to specific enrollee groups, offering non-health care benefits not traditionally covered by Medicaid (e.g. nutrition assistance), modifying enrollment processes, and changing the criteria for payments to hospitals for uncompensated care costs. 2. The proposal includes new flexibilities not currently offered by federal law or regulation. Examples include instituting a drug formulary, funding broad public health initiatives, supporting technology adoption in rural areas, and instituting lock-out periods or benefit sanctions for enrollees found guilty of defrauding the program. It also pitches the idea of allowing a longer or even permanent approval period for the TennCare waiver. 3. The draft includes exemptions from federal oversight requirements. TennCare is primarily asking to be exempt from federal regulations of Medicaid managed care programs. For example, these regulations require that states get federal approval of contracts and payment rates with managed care organizations (MCOs) ahead of time, maintain an MCO enrollee appeals process, and offer an MCO quality rating system. The proposal does not appear to include any changes that would affect eligibility. TennCare would have to go through the normal CMS approval process to expand or shrink eligibility. If TennCare were to ask to add new populations in the future, they would be separate from the federal funding allotment until costs become predictable. The proposed changes could have significant effects on TennCare spending, enrollees, and providers — either positive, negative, or mixed depending on if and how current or future state officials use that power. The proposal gives examples of how some of the flexibilities might be applied (e.g. to test pilot programs without federal approval), but it does not specify when or how state policymakers would use them. Without these details, there are few limits on the range of possible outcomes. The draft in its current form does not specify if and how the program might report on its use of these flexibilities and their impact. There are no rules for how TennCare would notify CMS, affected stakeholders, or the public when state officials decide to use these new powers. While TennCare proposes tracking expenditures and measures around access to care and health outcomes for the entire waiver, the draft does not say how TennCare might monitor, evaluate, and share findings on the effects of using specific flexibilities. TennCare’s recent record of instituting significant changes has had mixed results. In some circumstances, TennCare has been cited as a national leader in innovative payment and benefit models (e.g. value-based purchasing for behavioral health). (6) (7) (8) (9) In other cases, it has been criticized for how it has handled the implementation of major administrative changes (e.g. eligibility redetermination) and the monitoring of new initiatives (e.g. episodes of care). (10) (11) 2 SycamoreInstituteTN.org POLICY BRIEF Breaking Down TennCare’s Block Grant Proposal 3. How does the proposal change federal funding? Under the proposal, federal funding for most TennCare enrollees’ medical costs would be capped. Today, the federal government pays 65% of TennCare’s costs, and the state pays the remaining 35% (subject to the limitations discussed in question four). This 65-35 arrangement would be replaced by a fixed federal funding allotment for the affected enrollees/spending. Under the proposal, Tennessee would be responsible for 100% of any spending above the new federal allotment but could use part of any savings from spending less than the allotment without a state match requirement (Figure 1). Figure 1. How Funding Would Work Under TennCare’s Proposed Block Grant Total Federal Funding Allotment based on enrollee categoryspecific caps*, CBO-projected growth rates, and the higher of actual enrollment or enrollment in FYs 16-18. Financial Exposure If spending exceeds the allotment, TN would be responsible for 100% of the overage. Scenarios of Actual Spending Shared Savings If spending is below the allotment, TN would be able to tap 50% of the difference without any state match requirement. For illustrative purposes only. * TennCare’s draft block grant waiver as released on 9/17/2019 would exclude administrative costs, supplemental payments to hospitals, and pharmaceutical costs and exclude dual eligibles and enrollees in programs outside the 1115 TennCare waiver (e.g. DIDD waivers). Key details of the federal funding allotment include: 3 • Enrollee-Specific Per Capita Caps: TennCare’s federal funding allotment would be based on per capita amounts for four enrollee groups — children, adults, individuals with disabilities, and the elderly. Figure 2 shows average monthly enrollment across all five TennCare waiver groups in FY 2018. (12) The allotment would not apply to individuals eligible for both Medicare and TennCare (“dual eligibles”) or enrollees outside the main TennCare waiver (e.g. DIDD waivers). • Enrollee-Specific Cost Projections: Each year, the per capita costs would grow by the Congressional Budget Office’s (CBO) projected rates for each of the four enrollee groups (Figure 3). (13) • Enrollment: The federal funding allotment would be based on the higher of two metrics, either actual enrollment or enrollment in FYs 2016-2018 (i.e. “the base period”). SycamoreInstituteTN.org POLICY BRIEF Breaking Down TennCare’s Block Grant Proposal • Exclusions: Pharmaceutical costs, administrative costs, and supplemental payments for hospitals (e.g. for training physicians, uncompensated care) are all excluded from the allotment. • State Maintenance of Effort: The state could use the allotment to reduce its share of costs for the affected enrollees/spending below the current 35% as long as state spending does not fall below a “maintenance of effort” (MOE) level. This state spending floor would be based on FY 2019 expenditures. The details of this calculation are not specified. Figure 2. TennCare Enrollment by Category in FY 2018 Avg. Monthly TennCare Waiver Enrollment by Enrollee Category (FY 2018) 751,961 397,760 144,282 141,754 423 Children* Disabled Adults Aged Dual Eligibles** *Children include individuals 18 and under. TennCare’s draft block grant waiver as released on 9/17/2019 defines children as those under 21. **Dual eligibles are excluded from the federal funding allotment proposed in the draft waiver. Source: TennCare’s Quarterly Reports to CMS (12) Figure 3. TennCare’s Proposed Block Grant Would Grow Based on Federal Projections For Each Enrollee Group Congressional Budget Office Medicaid Per Capita Cost Projections by Enrollee Category (FFYs 2018- 2026) Avg. Annual Growth: 5.2% — Disabled 3.1% — Elderly 4.9% — Adults 6.1% — Children 2018 2019 2020 2021 2022 2023 2024 2025 2026 FFY = federal fiscal year Source: CBO’s May 2019 Baseline Projections (13) 4 SycamoreInstituteTN.org POLICY BRIEF Breaking Down TennCare’s Block Grant Proposal • Shared Savings: If TennCare does not spend the full federal allotment, Tennessee would be able to use 50% of those savings without any state match requirement. The waiver is not specific on how the funds could be used, but the supporting documents suggest they would be spent on “health-related services.” • Time-Limited (or Permanent?): The proposal amends the current TennCare waiver. Waivers typically last for three to five years, which would allow the state and federal government to periodically revisit the proposal. Waivers can be extended many times. In fact, the current waiver (which expires on June 30, 2021) is an extension of the “TennCare II” waiver that was first approved by the federal government in 2002. However, the draft also proposes that the federal government consider making Tennessee’s waiver permanent or extending the period beyond the typical five years. 4. How does TennCare’s funding work now? The proposal builds on some of the financial concepts already at work in TennCare. Because TennCare operates under a waiver, it must meet federal “budget neutrality” requirements. In other words, a state waiver cannot cost the federal government any more than it would be expected to spend in the absence of the waiver. Similar to this proposal, the current budget neutrality requirement creates a federal funding ceiling based on enrollee-specific per capita caps, cost projections, and actual enrollment. (14) The existing base per capita caps were established under the initial TennCare II waiver in 2002. Since then, the caps have increased in line with federal projections for Medicaid growth nationwide. CMS has also allowed savings (i.e. the difference between actual spending and the budget neutrality cap) from one waiver period to roll-over into subsequent extension periods. If a state exceeds its total budget neutrality ceiling after accounting for any rollover savings, it must repay the excess amount to the federal government. (15) Figure 4. TennCare’s Actual Costs for Most Enrollees Are Usually Below Current Federal Caps The TennCare Waiver’s Budget Neutrality Caps by Enrollee Category* vs. Actual Spending (FY 2014- FY 2018) Avg. Monthly Per Capita TennCare Costs: $2K Children*** $2K Adults Federal Cap Actual Spending** $2K $2K Disabled Elderly *Current federal budget neutrality requirements use a formula that includes avg. monthly per capita cost estimates to cap total program spending under 1115 waivers. **Includes pharmaceutical costs, which are excluded from the federal allotment proposed in TennCare’s draft block grant waiver as released on 9/17/2019. ***Children include individuals 18 and under. TennCare’s draft block grant waiver defines children as those under 21. Source: TennCare’s Quarterly Reports to CMS (12) 5 SycamoreInstituteTN.org POLICY BRIEF Breaking Down TennCare’s Block Grant Proposal TennCare has consistently remained below its total budget neutrality ceiling. Between 2003 and 2021, TennCare predicts the program will cumulatively spend $31 billion less than the federal budget neutrality caps. (16) Figure 4 shows TennCare’s average annual per capita costs for each enrollee category since FY 2014 alongside the federal caps. (12) 5. What is Tennessee’s financial risk under the proposal? By design, any fixed federal funding allotment comes with financial risk that could present trade-offs for state policymakers. Any downward pressure on federal TennCare funding might require state policymakers to balance the budget by making changes to TennCare, shifting money from other priorities, and/or raising taxes. All of these decisions would pose trade-offs. The formula that would set the allotment, as currently proposed, is heavily weighted in Tennessee’s favor — at least in the short-term. Both the details of each variable and how those details interact matter. Below, we outline how the proposal deals with some of the critical details that determine the state’s financial risk. • Base Amount: TennCare proposes an FY 2018 base of $7.9 billion, which would be adjusted each year based on the parameters discussed above and below. For context, Tennessee received $7.0 billion in total federal funding in FY 2018 for all TennCare expenses, not just those proposed for inclusion in the allotment. • Adjustments for Enrollment: TennCare enrollment during FYs 2016-2018 would be used to set a floor for the federal funding allotment. Enrollment during this base period was historically high (Figure 5) — even compared to the last recession. The allotment could be adjusted upward for changes in both overall enrollment and the mix of enrollee types. For example, the allotment would grow if a recession increased enrollment over the base period. It would also account for changes in the number of enrollees across each category even if overall enrollment remained stable. Figure 5. TennCare Enrollment Was Historically High During the Proposed Base Period for the Block Grant Waiver Millions Monthly TennCare Enrollment (Jan 2007 – Aug 2019) 1.7 1.6 The Great Recession Proposed Block Grant Base Period 1.5 1.4 1.3 1.2 1.1 1.0 0.9 0.8 The base period would be used for calculating the minimum federal funding allotment in TennCare’s draft block grant waiver as released on 9/17/2019. Source: TennCare’s Monthly Enrollment Data (17) 6 SycamoreInstituteTN.org POLICY BRIEF Breaking Down TennCare’s Block Grant Proposal • Accounting for Enrollee Differences: The proposed allotment accounts for nominal differences in spending patterns across the four different enrollee groups and differences in projected cost trends (Figure 3). • Per Capita Caps: The proposed allotment base uses the FY 2018 per capita caps from TennCare’s existing budget neutrality ceiling. TennCare’s average costs for most enrollees was well below these caps (Figure 4), which largely reflect estimates of national enrollee costs in the absence of a waiver. Beginning in 2021, however, CMS plans to “rebase” states’ caps according to each state’s recent experience, instead of national trends. (15) This is expected to reduce Tennessee’s per capita caps under budget neutrality. It is unclear how CMS might weigh its new policy against TennCare’s proposal. • National Medicaid Growth Trends: The draft proposal would grow each per capita cap using CBO trend projections. In recent history, TennCare’s actual costs and existing caps have grown slower than CBO projected for children, adults, and individuals with disabilities (Figure 6). Figure 6. TennCare’s Actual Costs and Existing Caps Have Grown Slower for Most Enrollees than CBO Projected Avg. Annual Per Capita Cost Growth by Enrollee Category During Current TennCare Waiver Period (2017-2021) CBO’s 2016 Projection TennCare’s Federal Budget Neutrality Cap Actual TennCare Costs through FY 2018 7.2% 5.3% 5.1% 4.9% 4.1% 3.4% 4.0% 3.4% 3.3% 2.3% Children* Adults -0.2% Disabled 1.9% Elderly The current TennCare waiver spans December 2016-June 2021. ***Includes pharmaceutical costs, which are excluded from the federal allotment proposed in TennCare’s draft block grant waiver as released on 9/17/2019. *Children include individuals 18 and under. TennCare’s draft block grant waiver defines children as those under 21. Sources: CBO’s 2016 Baseline Projections (18), TennCare’s Quarterly Reports to CMS (12) 6. What happens next? The public will have two chances to comment on this proposal before a decision by federal regulators, and the General Assembly must approve any final agreement before it takes effect. • • 7 TennCare’s release of its draft waiver kicks off a 30-day public comment period that will end on October 18, 2019. During this time, TennCare will also hold three public forums across the state. Under the 2019 law, TennCare must submit a revised draft to CMS by November 20, 2019. CMS will publish the submission and hold its own 30-day public comment period. Federal rules require SycamoreInstituteTN.org POLICY BRIEF • Breaking Down TennCare’s Block Grant Proposal CMS to wait at least 45 days total after publishing the waiver before it can be approved. Most statefederal negotiations over Medicaid waivers take much longer than that. (19) Tennessee’s General Assembly must approve any final agreement between the Lee administration and federal regulators before it could be implemented. (2) 7. What are the chances federal regulators approve this? These are relatively uncharted waters, so it is impossible to say. Here’s what we do know… The Trump administration appears motivated to approve an ambitious state Medicaid reform with broader state flexibilities. (20) However, there is little precedent for the kinds of changes in the current proposal, and some less ambitious proposals by states like Kansas and Massachusetts have been rejected recently. (21) Even if CMS and state lawmakers approve something along these lines, it is likely to face legal challenges that may ultimately halt implementation. The proposal would require significant deviations from previous interpretations of federal law and regulation, which will likely invite lawsuits. For example, many experts believe federal law does not allow the use of the waiver process to override the matching system that dictates Tennessee’s 65-35 split. (21) (22) (3) However, it is possible that the proposal is or could be structured to meet the technical funding requirements of federal law. THE SYCAMORE INSTITUTE The Sycamore Institute is an independent, nonpartisan public policy research center for Tennessee. Sign up for email alerts at: SycamoreInstituteTN.org Written By Mandy Pellegrin Policy Director mpellegrin@SycamoreInstituteTN.org Other Sycamore Staff Laura Berlind Executive Director Brian Straessle Director of External Affairs Brittney Anthony Assoc. Director of Operations & Engagement Ryan Bass Policy Analyst *Updated on 9/23/2019 to correct a typo in Figure 2. The "disabled" category was incorrectly labeled as "aged." 8 SycamoreInstituteTN.org POLICY BRIEF Breaking Down TennCare’s Block Grant Proposal References 1. TennCare. Draft of Amendment 42 to the TennCare II Demonstration. September 17, 2019. Obtained from https://www.tn.gov/tenncare/policy-guidelines/waiver-and-state-plan-public-notices.html. 2. State of Tennessee. Public Chapter No. 481 (2019). May 24, 2019. https://publications.tnsosfiles.com/acts/111/pub/pc0481.pdf. 3. United States of America. Section 1115 of the Social Security Act. https://www.ssa.gov/OP_Home/ssact/title11/1115.htm. 4. Brian Neal. CMCS Informational Bulletin: Section 1115 Demonstration Process Improvements. Centers for Medicare and Medicaid Services (CMS) Center for Medicaid and CHIP Services. November 6, 2017. https://www.medicaid.gov/federal-policy-guidance/downloads/cib110617.pdf. 5. Centers for Medicare and Medicaid Services (CMS). 1115 Demonstration State Monitoring & Evaluation Resources. https://www.medicaid.gov/medicaid/section-1115-demo/evaluation-reports/evaluation-designs-andreports/index.html. 6. Soper, Michelle Herman, Matulis, Rachael and Menschner, Christopher. Moving Toward Value-Based Payment for Medicaid Behavioral Health Services. Center for Health Care Strategies, Inc. June 2017. https://www.chcs.org/media/VBP-BH-Brief-061917.pdf. 7. Smith, Derica and Hanlon, Carrie. Case Study: Tennessee’s Perinatal Episode of Care Payment Strategy Promotes Improved Birth Outcomes. National Academy for State Health Policy and the National Institute for Children's Health Quality. October 2017. https://nashp.org/wp-content/uploads/2017/10/Tennessee-CaseStudy.pdf. 8. Spencer, Anna and Crawford, Maia. Promising State Innovation Model Approaches for High-Priority Medicaid Populations: Three State Case Studies. Center fo Health Care Strategies, Inc. March 2019. https://www.chcs.org/media/Promising-State-Innovation-Model-Approaches.pdf. 9. Honsberger, Kate and Hanlon, Carrie. Tennessee: Using Managed Care Incentives to Improve Preventive Services and Care for Children. National Academy for State Health Policy. January 2018. https://nashp.org/wpcontent/uploads/2018/01/Tennessee-Case-Study-2018.pdf. 10. Tennessee Comptroller of the Treasury. Review of TennCare Eligiblity Redeteriminations. December 6, 2017. https://comptroller.tn.gov/content/dam/cot/sa/advanced-search/2017/tenncarememoandreport.pdf. 11. —. Performance Audit Report: Division of TennCare. [Online] December 2018. https://comptroller.tn.gov/content/dam/cot/sa/advanced-search/2018/pa18043.pdf. 12. TennCare. Quarterly Reports to the Federal Centers for Medicare and Medicaid Services. 2013-2019. Obtained from https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiverlist/?entry=8387. 13. Congressional Budget Office (CBO). Medicaid—CBO's May 2019 Baseline. May 2019. https://www.cbo.gov/system/files/2019-05/51301-2019-05-medicaid.pdf. 14. TennCare. TennCare 1115 Demonstration Agreement with CMS. July 2, 2019. https://www.tn.gov/content/dam/tn/tenncare/documents/tenncarewaiver.pdf. 15. Hill, Timothy B. SMD # 18-009 RE: Budget Neutrality Policies for Section 1115(a) Medicaid Demonstration Projects. Centers for Medicare and Medicaid Services (CMS) Center for Medicaid & CHIP Services. August 22, 2018. https://www.medicaid.gov/federal-policy-guidance/downloads/smd18009.pdf. 16. TennCare. Appendix B: Anticipated Impact on Budget Neutrality. Draft of TennCare II Demonstration: Amendment 41. September 9, 2019. https://www.tn.gov/content/dam/tn/tenncare/documents2/Amendment41.pdf. 17. —. Monthly Enrollment Data. 2013-2019. Obtained from https://www.tn.gov/tenncare/informationstatistics/enrollment-data.html. 18. Congressional Budget Office (CBO). Detail of Spending and Enrollment for Medicaid for CBO's March 2016 Baseline. March 2016. https://www.cbo.gov/sites/default/files/recurringdata/51301-2016-03-medicaid.pdf. 19. Centers for Medicare and Medicaid Services (CMS). 42 CFR Part 431. February 27, 2012. https://www.govinfo.gov/content/pkg/FR-2012-02-27/html/2012-4354.htm. 20. Verma, Seema. Speech: Remarks by Administrator Seema Verma at the National Association of Medicaid Directors (NAMD) 2017 Fall Conference. Centers for Medicare and Medicaid Services. November 7, 2017. https://www.cms.gov/newsroom/fact-sheets/speech-remarks-administrator-seema-verma-national-associationmedicaid-directors-namd-2017-fall. 21. Hinton, Elizabeth, et al. Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers. Kaiser Family Foundation. February 12, 2019. https://www.kff.org/medicaid/issuebrief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers. 22. Medicaid and CHIP Payment and Access Commission (MACPAC). Medicaid 101: Waivers. https://www.macpac.gov/medicaid-101/waivers/. 9 SycamoreInstituteTN.org HIL ARY W. HOYNES University of California, Berkeley DIANE WHITMORE SCHANZENBACH Northwestern University Safety Net Investments in Children ABSTRACT    In this paper, we examine what groups of children are served by core childhood social safety net programs—including Medicaid, EITC, CTC, SNAP, and AFDC/TANF—and how they have changed over time. We find that virtually all gains in spending on the social safety net for children since 1990 have gone to families with earnings, and to families with income above the poverty line. These trends are the result of welfare reform and the expansion of in-work tax credits. We review the available research and find that access to safety net programs during childhood improves outcomes for children and society over the long run. This evidence suggests that the recent changes to the social safety net may have lasting negative effects on the poorest children. A persistently large number of children in the United States live in poverty, despite sustained economic growth. Recognizing the social and moral imperative to alleviate child poverty, the United States has a patchwork of tax and transfer programs that target low-income families with children and seek to reduce child poverty. In 2016, the federal government spent about $200 billion on such programs, and they had a substantial impact on reducing child poverty.1 Including the value of government taxes and transfers, these efforts reduce child poverty from 25 percent (no taxes Conflict of Interest Disclosure: Hilary W. Hoynes is a board member for the California Budget & Policy Center. The authors did not receive financial support from any firm or person for this paper or from any firm or person with a financial or political interest in this paper. With the exception of the aforementioned, they are currently not officers, directors, or board members of any organization with an interest in this paper. No outside party had the right to review this paper before publication. 1. This includes spending on families with children through the Earned Income Tax Credit, the Child Tax Credit, the Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, and public housing; and spending on children through Medicaid and Supplemental Security Income. Our data and these calculations are discussed below. 89 90 Brookings Papers on Economic Activity, Spring 2018 or transfers) to 15 percent (current law) (Shapiro and Trisi 2017)—lifting 7.4 million children out of poverty. Yet 11.1 million children are still living in poverty. Growing up poor not only harms children in the short run; by limiting investments in their human capital, it also harms them in the long run. Thus, considerable government tax and transfer spending on children is aimed at reducing poverty—with a justification primarily on humanitarian grounds. In contrast, another substantial public sum is spent on child human capital policies where an investment (rather than humanitarian) criterion is employed. In a standard human capital investment model, resources are spent up front that generate returns over the longer run across a variety of measures—potentially including better labor market outcomes, improved health, and higher educational achievement. Early childhood education programs are promoted within this framing, and, more generally, the provision of public education is a primary mechanism for U.S. investments in children. Many compelling studies have found that there is also a substantial investment component to safety net programs that alleviate childhood poverty, suggesting that it is also appropriate to consider a portion of safety net spending through the investment framework. However, to date, the investment component of safety net spending has not been widely discussed. This paper is motivated by our interest in summarizing what is known about the long-run benefits of childhood safety net benefits and in reevaluating current policies in light of this evidence. There are three components to this paper. First, we review the research evaluating the long-run effects of social safety net benefits, which shows that investments in early life can have large effects on later-life outcomes—perhaps strong enough to suggest that reallocation of investments over the life course to earlier periods can be efficiency-enhancing. Recent research has focused on quantifying the social safety net’s benefits for health and productivity in adulthood. In particular, we review the available evidence about the three pillars of the U.S. social safety for families with children: the Supplemental Nutrition Assistance Program (SNAP), the Earned Income Tax Credit (EITC), and Medicaid. These studies suggest that in addition to the humanitarian and social insurance reasons to have a safety net, there is also a supply-side case. That is, providing certain safety net programs ends up benefiting children and society over the long run. And these investments have both private and public benefits. The findings we consider imply that the benefits of the social safety net are broader than is commonly assumed—and indeed, that this spending yields downstream benefits to taxpayers (through HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 91 increased tax revenues and potential declines in spending on health care and the safety net), in addition to the affected families. Second, we analyze the data on government spending on children, how it features in broader public spending, and how it has changed over time. Overall, we find that government spending is not in line with our increasing understanding of the importance of resources during early life, and the positive spillovers from safety net spending on children.2 The United States spends a relatively small amount on children, and spending has remained relatively flat over the last two decades, at between 1.5 and 2 percent of GDP (Isaacs and others 2017). In contrast, per capita spending on the elderly in the United States has grown substantially over the same period, and in 2015 amounted to 9.3 percent of GDP.3 U.S. spending on children is very low by international standards; the United States is near the bottom of countries belonging to the Organization for Economic Cooperation and Development (OECD) in “family benefits public spending” as a share of GDP (third from the bottom, above only Mexico and Turkey), with a share less than half the OECD average.4 Yet U.S. spending on the elderly, based on “pension spending” as a share of GDP, is just below the OECD average.5 We also analyze how the composition of spending on children has changed over time. Fundamental changes have occurred in the social safety net for children in the past 25 years. The EITC expanded substantially, creating subsidies to work; welfare reform dramatically reduced the availability of cash assistance; and health insurance for low-income children expanded dramatically through Medicaid. We use a unique approach, based on administrative data, to examine who is benefiting from changes to the social safety net and who is being left behind. In particular, we estimate the changes over time in how government spending is allocated across the income distribution (for example, those below the poverty line versus those above it) and how it is allocated across working and nonworking families. This analysis shows that there have been substantial shifts in their composition over the past 20 years. We find that an increasing share is going to children near and above the poverty threshold, while a decreasing 2.  The 2017 tax reform legislation includes an expansion of the Child Tax Credit, including the refundable portion that is targeted to lower-earning families. 3.  Some of the elderly spending may have spillovers onto children. For example, providing Social Security benefits to grandparents frees up some family resources that may be spent on children. 4.  This is as of 2013. The data are available at https://data.oecd.org/socialexp/familybenefits-public-spending.htm. 5.  This is as of 2013. The data are available at https://data.oecd.org/socialexp/pensionspending.htm. 92 Brookings Papers on Economic Activity, Spring 2018 share is directed to the poorest children living below the poverty threshold— despite a relatively stable share of children living in poverty. There has also been a massive shift toward in-work transfers and health insurance, with a declining share in unrestricted cash benefits. Our approach, which uses administrative data wherever possible, makes an important contribution because it circumvents the well-documented undercounting of safety net spending in survey data, the source of data typically used to examine the composition of spending. Pulling the paper’s two sections together, we evaluate the state of the social safety net for families with children. The literature is not sufficiently developed to provide strong guidance on precisely how to optimally allocate funds across eligible groups, and across different programs. Nonetheless, the broad patterns are clear: The research shows there are important benefits to having access to the safety net during childhood that should be considered by policymakers. Furthermore, there are strong returns across the cash, tax-based, near-cash, and health insurance programs that we examine, with potentially larger effects for the most disadvantaged children. These consistent findings imply that we are spending too little on children and their families. And the decline in the availability of benefits for the most disadvantaged children, primarily due to welfare reform, is likely to lead to worse outcomes for these children in adulthood. Any cuts to current programs that will reduce resources going to children would have direct, negative effects on children in both the short and long terms. It is also crucial to recognize that the modal recipient family is combining safety net use with employment; the view that all spending is welfare and going to out-of-work families is not the case. Instead, the social safety net is acting to increase earnings to help families make up for stagnating and declining wages (Autor 2014). In light of this, it is important to make sure that policies can work in alignment with the labor market. Specifically, policymakers should refrain from adding work disincentives to programs—such as eligibility notches that abruptly remove access to benefits above an income threshold—and ensure that programs can respond quickly to replace lost income during recessions. I.  An Overview of the Private and Public Safety Net for Children We begin by describing the broader set of social safety net programs for children in the United States, how they compare with spending for other groups, and how this has changed over time. Figure 1, reproduced from 93 HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH Figure 1.  Spending and Tax Programs with the Highest Federal Expenditures on Children, 2016 Medicaid Earned Income Tax Credit Child Tax Credit Dependent exemption Supplemental Nutrition Assistance Program Child nutrition Employer-sponsored insurance Outlays Tax reductions Social Security Title I Children’s Health Insurance Program Special education Temporary Assistance for Needy Families Supplemental Security Income Other 10 20 30 40 50 60 70 80 90 Billions of 2016 dollars Source: Isaacs and others (2017). a report by Julia Isaacs and others (2017), details federal expenditures on children in 2016. The spending takes the form of tax expenditures (for example, the EITC, Child Tax Credit, dependent exemption, and tax exclusion of employer-provided health insurance), direct transfers to families (for example, SNAP, Social Security, Temporary Assistance for Needy Families, and Supplemental Security Income), and transfers from the federal to state and local governments (for example, Title I and special education). Note that this figure focuses on federal spending on children, and omits the sizable transfers made by states, including the state share of Medicaid and child welfare services, state EITCs, and state education spending. A number of programs provide benefits to low-income children ranging from cash to insurance. Medicaid, which provides public health insurance to low-income children, is the largest program, with $89 billion spent 94 Brookings Papers on Economic Activity, Spring 2018 annually on children (after removing the share spent on the elderly and disabled). The Children’s Health Insurance Program (CHIP) ($14 billion) is another public health insurance program; it supports children in families with income above the Medicaid eligibility limits. The EITC ($61 billion) is a refundable tax credit for working families with children.6 In 2017, the maximum EITC credit was $5,616 for families with two children, and $3,400 for those with one child. More than 40 percent of tax filers with children received the EITC. The Child Tax Credit (CTC) ($50 billion) is a partially refundable tax credit of $1,000 for each child in working families.7 The CTC provides important benefits to low-income families with children, but a substantial share of the CTC’s cost goes to families much higher up in the income distribution.8 SNAP ($31 billion) provides vouchers for food assistance, and eligibility is generally limited to those with an income below 130 percent of the federal poverty line. In 2017, the average monthly SNAP benefit was $125 per person. In contrast to the tax credits, both working and non­working families are eligible for SNAP. The other child nutrition programs ($22 billion) include the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) as well as the National School Lunch Program and School Breakfast Program, which provide free and reduced-price school meals. Historically, a cornerstone of the safety net was Aid to Families with Dependent Children (AFDC), a cash welfare program not tied to work. The program was overhauled in 1996 into Temporary Assistance for Needy Families (TANF), block-granting it to states, which were allowed tremendous flexibility in administering the program, with funds frozen at their 1996 level in nominal terms, and strict work requirements and lifetime limits enacted (Bitler and Hoynes 2016). Today, only 2.4 percent of the child-based safety net spending goes to TANF, and the program’s reach is low—only 23 percent of children in poor families received TANF cash assistance in 2016, compared with 76 percent in 1996 (Floyd, Pavetti, and 6.  There is also a small credit for low-income working families without children; these dollars are excluded from the calculations presented here. 7.  The refundable portion of the CTC is known as the Additional Child Tax Credit and is limited to 15 percent of earned income above $3,000. Throughout this paper we present the combined Child Tax Credit and Additional Child Tax Credit and refer to it simply as the CTC. 8.  In 2017, the $1,000 credit is phased out starting at incomes of about $80,000 ($120,000) for single parent (married couple) families. The credit is fully phased out at incomes of about $100,000 ($130,000) for single parent (married couple) families. The 2017 tax law reforms the CTC to raise the credit amount and expand the range of income over which families are eligible. 95 HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH Figure 2.  Per Capita Spending on Children and the Elderly, 1980–2015 2015 dollars Elderly (federal) 30,000 20,000 Children (federal, state, and local) 10,000 Children (federal) 1985 1990 1995 2000 2005 2010 Year Sources: Isaacs and others (2017); U.S. Department of Education; authors’ calculations. Schott 2017).9 Supplemental Security Income (SSI) is another cash welfare program, providing benefits to low-income disabled and elderly persons. After a court decision in 1990, the definition of disability was expanded to allow more children to receive SSI (Duggan, Kearney, and Rennane 2016). Notably, figure 1 shows that cash welfare is a very small share of U.S. social safety net spending on children. Instead, most spending on children consists of public health insurance, tax credits that are linked to paid work (the EITC and CTC), and SNAP. Figure 2, which is adapted from Isaacs and others (2017), contrasts trends in federal spending on children and the elderly for 1980–2015.10 To   9.  TANF accounts for 2.4 percent of all spending items in figure 1. If we limit the set of programs to cash and near-cash direct transfers to households (dropping Medicaid, CHIP, Title I, and special education) and omit the tax reductions (the dependent exemption and the value of untaxed employer-sponsored insurance), TANF still remains below 5 percent of spending. 10.  A large share of the federal spending on the elderly is for Medicare and Social Security. Those programs also serve some nonelderly (primarily disabled adults); the trends shown in figure 2 omit the spending on adults. Although much smaller, we also limit SSI to the spending on the elderly (dropping spending on disabled children and adults). Child spending is the total of programs shown in figure 1. 96 Brookings Papers on Economic Activity, Spring 2018 account for trends in population size, each category is presented in terms of spending per capita (for example, per child or per elderly person), in inflation-adjusted 2015 dollars. Per capita federal spending on the elderly is currently $35,000 and has doubled over this period. To be sure, spending on the elderly is not entirely analogous to spending on children—for example, part of spending on the elderly is a pension linked to prior work and payroll taxes, and a higher share comes in the form of health insurance. However, two points to recognize are that spending on the elderly is relatively generous, and it also involves substantial redistribution to the lower-income elderly. Per capita federal spending on children is only about $5,000 a year. When spending on public elementary and secondary schools is included—$11,222 per pupil in the most recent year spent at the state and local levels—total spending on children increases, but a large gap in per capita spending remains. At the end of this period, in 2015, federal spending on children was only 2.1 percent of GDP, compared with more than 9 percent for the elderly. More striking is the significant growth in per capita spending for the elderly alongside the modest spending levels and upward trends for children. This imbalance has implications for future productivity, given the fact that spending on children can be viewed as an investment while spending on the elderly is not. Trends in public spending should be analyzed alongside trends in private resources available to children. By some measures, including parental time with children (proxied by the number of parents in a household) and income, children in lower-income households have stagnant or fewer private resources available. As shown in figure 3, over the past 40 years there has been a marked decline in the share of children living with married parents among children whose mothers have less than a college education; in 2015, only 60 percent of children with mothers without a college degree lived with married parents, compared with 85 percent of children with college-educated mothers. During the same period, large numbers of both single and married mothers joined the workforce, as shown in figure 4. Since 2000, single mothers’ labor force participation rate has been nearly identical to that of single childless women (Black, Schanzenbach, and Breitwieser 2017), and above the participation rate of married women with children. However, real wages among workers with low levels of education have been stagnant or declining, as shown in figure 5. As we show in section III, an increasing share of benefits is going to families that combine work with safety net use, and the safety net is supporting families that face stagnant economic opportunities. Finally, along some other dimensions, there have been positive changes in the private resources available to 97 HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH Figure 3.  Percentage of Children with Married Parents, 1975–2015 Percent Mother has a college degree 90 80 Mother does not have a college degree 70 60 1980 1985 1990 1995 Year 2000 2005 2010 Sources: Current Population Survey, Annual Social and Economic Supplement; authors’ calculations. Figure 4.  Percentage of Children with a Working Mother, 1975–2015a Percent Single mother 70 Married mother 60 50 1980 1985 1990 1995 Year 2000 2005 2010 Sources: Current Population Survey, Annual Social and Economic Supplement; authors’ calculations. a. The sample is restricted to mothers age 25–54. 98 Brookings Papers on Economic Activity, Spring 2018 Figure 5.  Trends in Real Wages of Full-Time Workers, 1991–2015a Men Index, 1991 = 100 College 110 Some college 100 High school 90 Less than high school 1995 2000 2005 2010 2005 2010 Year Women Index, 1991 = 100 110 100 90 1995 2000 Year Sources: U.S. Bureau of Labor Statistics; authors’ calculations. a. The sample is restricted to workers age 25 and above. HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 99 children, including a decline in the total number of children per family, and an increase in parental education.11 As we proceed below, our analysis focuses on a subset of federal safety net programs with substantial spending on low-income children. We are particularly interested in discussing those programs and policies for which we have evidence on their long-run effects on children. Therefore, in the rest of the paper, we cover Medicaid, EITC, CTC, SNAP, TANF, public housing, and SSI.12 As shown in figure 1, this captures four of the top five programs in expenditures. II.  Findings from the Recent Literature In recent years, researchers have made strong advances toward understanding the long-run effects of safety net spending and other early-life events. This research—which has very recently been reviewed by Douglas Almond, Janet Currie, and Valentina Duque (forthcoming)—shows that there are critical times both during the prenatal period and in early childhood that deserve a particular policy focus. This line of inquiry has been based on a large body of literature spanning work on public health, epidemiology, and, more recently, economics that documents important laterlife effects of extreme negative shocks on health and mortality—such as famines, wars, and the 1918 flu pandemic. Much of the early work focused on prenatal exposure to shocks, and tested David Barker’s (1990) “fetal origins” hypothesis. Barker argued that a poor prenatal environment (in particular, inadequate nutrition) “programs” the fetus to be at higher risk of metabolic conditions and disease risk in adulthood. The economic liter­ ature subsequently documented that these extreme negative shocks also 11.  Over this period, parental educational attainment has increased. Whereas the median mother had only a high school education in the early 1990s, beginning in 1995, the median mother had some college education. Due to these educational attainment changes, the trend for the low education group may partially reflect compositional changes, rather than structural trends. In fact, if we instead reexamine figure 3 for women with below-median (versus above-median) educational attainment, the trends in child living arrangements are much more stable. Throughout the period, about 60 percent of children with a low-educated mother (below median educational attainment) lived with married parents. The increase in employment among low-educated mothers is similar over our period under both measures, but rises slightly less for highly educated mothers using the alternative definition (above median). 12.  Below, when we present more detailed data on the CTC, we consider expenditures on the tax credit that go to families with income below 200 percent of the federal poverty line. This allows us to incorporate this relatively large program but to limit it to our population of interest. 100 Brookings Papers on Economic Activity, Spring 2018 have a negative impact on economic well-being—including educational attainment, IQ, and earnings.13 As the literature has continued to evolve, it has turned to testing milder, commonplace shocks, encompassing positive as well as negative shocks. These studies have further documented the importance of the postnatal environment—particularly early childhood— to identify effects, leveraging variation in access to nutrition, maternal stress, exposure to alcohol and tobacco, and environmental toxins and public health interventions. The literature clearly supports the conclusion that relatively mild early-life shocks can have effects on later-life health and labor market outcomes. More recently, this literature has turned to evaluating the effects of the social safety net on long-run outcomes. To do this work, a number of factors must come together. First, adequate longitudinal data are necessary, including information both about childhood circumstances and adult outcomes. In some cases, the year of birth and the location of birth or residence in early life are sufficient to determine whether the individual had access to a program. In other cases, information on measures or proxies for family income during childhood is also necessary. Much of the pathbreaking work on early-life influences and later-life outcomes has come from countries with extensive individual-level panel data, like Norway and Sweden, but such data are typically harder to come by in the United States. Because safety net programs typically serve people who need the program when they need it, it is empirically difficult to disentangle the (likely positive) impact of the safety net from the (likely negative) impact of the circumstances that made a family eligible for the program. To overcome this challenge, researchers need a credible research design that allows them to isolate the impact of the program—and that can be implemented with the available data. Of course, long-term effects can only be measured after an appropriate amount of time passes; this is true broadly across the literature that evaluates the long-term effects of early life events. Before the availability of longer-term outcomes, many studies examined short-term proxy measures such as birth weight—which has been shown to be an important marker of long-run outcomes and which is often more readily available. There is consistent evidence, for example, that links birth weight to cognitive outcomes in childhood (Figlio and others 2014; Bharadwaj, Løken, and Neilson 2013) as well as a wide range of adult outcomes, such as wages, disability, adult chronic conditions, and human capital accumulation (Almond, Currie, and 13.  For excellent reviews of the early literature, see Almond and Currie (2011a, 2011b). HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 101 Duque, forthcoming). Other studies use educational measures as shortterm proxies, such as test scores. As longer-term data become available, many studies have revealed larger long-term effects across a wider variety of measures than the short-run proxies would have implied (Krueger and Whitmore 2001; Ludwig and Miller 2007; Deming 2009; Chetty and others 2011). In particular, outcomes in adulthood need not operate solely though health at birth (Almond, Chay, and Lee 2005; Almond and Currie 2011b). This suggests that a complete analysis of the long-run effects of the social safety net on children requires observing outcomes for affected children when they reach adulthood. Because of the time lag required for measuring long-term outcomes, the evidence we report here is necessarily related to programs that were implemented or expanded two decades ago or earlier. To the extent that these policies have been similar over time, or that the effects measure basic economic channels through which policies flow, these evaluations of older programs are still relevant today. Conversely, if circumstances or policies have changed dramatically, then the inference to today’s policies may be more limited. In the subsections that follow, we present evidence from the four primary types of safety net programs for low-income families, covering in-kind food benefits, tax credits linked to paid work, unconditional cash transfers, and public health insurance.14 We include studies that produce causal estimates of the impact of the safety net on long-run outcomes, and related work on short- and medium-run effects. As described below, each program type has been evaluated using credible research designs that are capable of identifying the causal impact of program access or participation on a range of outcomes. II.A.  In-Kind Food Benefits: The Supplemental Nutrition Assistance Program SNAP is a means-tested voucher program designed to supplement low-income families’ food budgets. The vouchers are structured to fill the gap between the resources a family has available to purchase food and the resources required to purchase an inexpensive food plan. Eligible families typically have an income below 130 percent of the poverty line. A maximum benefit is extended to those with $0 income, and the benefit is phased out at a 30 percent rate with increases in income (after deductions). Vouchers are paid monthly and can be used to purchase most foods at grocery stores 14.  See Almond, Currie, and Duque (forthcoming), Butcher (2017), and Sherman and Mitchell (2017) for other reviews of these studies. 102 Brookings Papers on Economic Activity, Spring 2018 and farmers’ markets that are intended to be taken home and prepared. In 2016, 13.6 percent of the population participated in SNAP, and average monthly benefits were $255 per household, or $126 per person. After accounting for the underreporting of benefits, SNAP is estimated to have lifted 3.8 million children out of poverty in 2015 (Wheaton and Tran 2018). Economic theory predicts that inframarginal participants—that is, those who receive SNAP benefits in an amount less than they would other­wise spend on food, who constitute the vast majority of participants—will treat their benefits like cash. There is some empirical debate about whether SNAP benefits are spent in the same manner as an equivalent cash transfer would be, or if instead the marginal propensity to consume food is higher out of SNAP than from regular income (Hoynes and Schanzenbach 2009; Hastings and Shapiro, forthcoming). In any case, SNAP represents a sizable income transfer to participants and is expected to change the amount or quality of food purchased. Like any means-tested income transfer that is not conditioned on work, there are potential disincentive effects on work effort. Understanding the effect of a program on work is relevant for quantifying the impact on total household financial resources, and also for parental time spent with children. Studies find that such effects for SNAP are small in practice (Hoynes and Schanzenbach 2009; East 2018). There have been relatively few expansions or other changes in SNAP that yield a credible research design to study the effects of the program. Benefit levels do not vary by geography (except for Alaska and Hawaii), and eligibility is universal and typically is only conditioned on income and assets. One source of variation leveraged by researchers is the program’s gradual, cross-county introduction during the 1960s and 1970s. Another source was the temporary exclusion of legal immigrants from the program, a restriction that was adopted in 1996 as part of the welfare reform law and was reversed in 2003. Using cross-county variation in the timing of the introduction of SNAP and Vital Statistics data on the universe of births in the United States, Almond, Hoynes, and Schanzenbach (2011) find that SNAP reduced the incidence of low birth weight by 7 percent for whites and 5 to 11 percent for blacks. In addition, although results are not statistically significant, point estimates suggest that the introduction of food stamps reduced neonatal mortality. Examining legal immigrants’ loss of benefits in the years after welfare reform, Chloe East (2017) finds that parental access to SNAP during pregnancy improves the child’s health at birth, as measured by birth weight. She also examines the impact on medium-run health, finding that a child’s SNAP access before age five improves the child’s parent-reported HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 103 health in adolescence. She finds suggestive evidence that SNAP reduces school absences, doctor visits, and hospitalizations—all of which are suggestive of long-term benefits. Hoynes, Schanzenbach, and Almond (2016) provide direct evidence, finding that childhood access to SNAP improves adult health status and economic outcomes. In particular, individuals with access to food stamps in childhood had better health in adulthood—as measured by a “metabolic syndrome index,” which combines measures of obesity, body mass index, and the presence of chronic conditions such as diabetes and high blood pressure. There are similarly positive overall effects on economic outcomes, as measured by a “self-sufficiency index” that includes current earnings and family income, and indicator variables for whether the individual graduated from high school, is currently employed, is currently not living in poverty, and is not participating in TANF or SNAP. The effects were largest among those who had access at the youngest ages, particularly between birth and age 5, underscoring the importance of providing protection in early childhood (Barker 1990; Heckman 2006). Although health improvements were similar across gender, the economic selfsufficiency improvements were present only for women (with small and statistically insignificant effects for men). The long-term effects were largest for those who spent their childhoods in the most disadvantaged counties. WIC is another food and nutrition program, providing vouchers for purchases of specific food items (for example, fortified cereal, eggs, cheese, milk, juice, and dried legumes) to pregnant and postpartum women, infants, and children under age 5. Families with an income below 185 percent of poverty are eligible for WIC. Despite the relatively low budget cost of WIC ($6 billion in 2016), the program’s reach is significant, especially to the youngest children—about half of births are to WIC recipients (Hoynes and Schanzenbach 2015). There is a large set of studies with robust evidence that WIC benefits for pregnant women lead to improvements in birth weight and infant health. This is suggestive that WIC may also lead to long-run improvements, though this has yet to be tackled in the research. II.B.  Tax Credits Tied to Paid Work: The Earned Income Tax Credit A large and increasing share of safety net programs are tied to employment. The most important of these programs is the Earned Income Tax Credit. The EITC is available to lower-income families with positive earned income. It is refundable, so when a family’s income is too low to generate tax obligations, the family receives a refund check from the Internal Revenue Service. In 2017, a single mother with two children with earnings 104 Brookings Papers on Economic Activity, Spring 2018 between $14,040 and $18,340 (a full-time, full-year, minimum wage worker earns $15,080) would receive the maximum credit of $5,616, fully 40 percent of pretax earnings. In 2015, the average benefit for families with children was $3,189 (Internal Revenue Service 2017). The Child Tax Credit is similar in structure to the EITC but is available to families earning substantially more than the EITC. Also, the CTC is not fully refundable, which limits the ability of lower-income families to benefit from the program (Hoynes and Rothstein 2016). Together, these tax credits represent the largest antipoverty program for children; the EITC and the CTC raised 4.8 million children out of poverty in 2015 (Renwick and Fox 2016).15 Because the EITC is only available to families with a positive earned income, the credit is expected to lead to increases in employment, especially among less-skilled workers.16 The research finds consistent evidence that the EITC leads to increases in employment (Hoynes and Rothstein 2016; Nichols and Rothstein 2016). For example, Bruce Meyer and Dan Rosenbaum (2001) find that the EITC raised employment by more than 7 percentage points for single women with children relative to those without children between 1984 and 1996. As shown by Hoynes and Ankur Patel (forthcoming), the household earnings gain resulting from the increase in employment is as large a component of the increase in household aftertax income as the government outlay from the EITC. This is important because it establishes a strong “first stage” for the effect of the EITC on family resources. More generally, changes in maternal employment may have direct effects on children—which are potentially positive, to the extent that employment brings more income to the family, or which are potentially negative, to the extent that the child attends low-quality child care or receives fewer time investments from his or her parents. In sum, because the EITC provides both a direct income transfer to families and a boost to maternal employment, studies of the EITC are measuring a dual “treatment.” A recent and growing body of literature uses the increase in after-tax income generated by the EITC to examine effects on downstream outcomes. These studies use quasi-experimental approaches leveraging legis­ lated expansions of the EITC. Many studies focus on the EITC’s 1993 15.  There is little research on the CTC, though one would expect similar effects as for the EITC where the two programs overlap. All the studies of the short- and long-term benefits of the tax credits come from an analysis of the EITC. 16.  One exception is secondary earners married to low-income primary earners; hours of work are predicted to fall for those secondary earners (Eissa and Hoynes 2004). HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 105 expansion, when the maximum credit more than doubled for families with two children and increased by more than 40 percent for those with one child. This policy variation is leveraged using a difference-in-differences approach, with comparisons across time and family size. The EITC has been expanded several other times (in 1986, 1990, and 2009), providing additional variation for researchers. Other researchers use the schedule of the credit—which is phased in at low earnings levels, is level across some income range, and then is phased out above a higher earnings level, providing variation that can be used for research—to estimate its effects. In addition, 29 states and the District of Columbia have adopted state add-on EITC programs, providing another source of variation. Several studies find that the EITC leads to increases in infant health, including an increase in average birth weight (Baker 2008; Strully, Rehkopf, and Xuan 2010). Hoynes, Doug Miller, and David Simon (2015) find that a $1,000 increase in after-tax income due to the EITC leads to a 2 to 3 percent reduction in low-birth-weight births. William Evans and Craig Garthwaite (2014) find that the EITC leads to improvements in maternal health, including reducing the incidence of risky biomarkers—such as measures of inflammation, high blood pressure, and elevated cholesterol— and improving mental health, suggesting an income pathway for a reduction in stress. There are also several studies that document a link between the EITC and cognitive and human capital outcomes. Gordon Dahl and Lance Lochner (2012, 2017) use an instrumental variables approach leveraging the EITC expansions and find that a $1,000 increase in a family’s income due to the EITC leads to an increase in combined mathematics and reading test scores of 0.04 standard deviation. Raj Chetty, John Friedman, and Jonah Rockoff (2011), using the nonlinearity of the EITC schedule and administrative data from the New York City public schools, find that a $1,000 increase in income due to the EITC leads to an increase in test scores of 0.06 to 0.09 standard deviation.17 Jacob Bastian and Katherine Michelmore (2018) find that a larger EITC during childhood leads to an increase in high school completion, college attendance, and employment in young adulthood. These effects are more important, they find, for the EITC received in the teenage years. Additionally, Day Manoli and Nicholas Turner (2018) 17.  In a related paper, Milligan and Stabile (2011) use variation across Canadian provinces in the generosity of child tax benefits over time, and find quantitatively similar effects on children’s cognitive test scores. They also find positive contemporaneous effects on mental health and some physical health outcomes. 106 Brookings Papers on Economic Activity, Spring 2018 and Michelle Maxfield (2013) look at the contemporaneous effects of a more generous EITC on education and the transition to college. Both studies find that the impact is larger for children affected at younger ages, while Maxfield also finds larger effects for boys and minority children. Manoli and Turner use the universe of federal tax records and the nonlinearity of the EITC’s schedule to examine the EITC’s effect in the senior year of high school on college attendance. They find that an additional $1,000 EITC leads to an increase in college attendance of 2 to 3 percentage points. Although direct evidence on longer-term outcomes beyond educational attainment is limited, we would expect that the increase in human capital shown in the literature will result in better adult economic and health outcomes, similar to those found for other interventions. II.C.  Unconditional Cash Transfers Beginning in 1935, the AFDC program provided cash assistance to poor families—primarily single-mother families—with children. There is little evidence on the long-run effects of the AFDC program, though Currie and Nancy Cole (1993) find that it led to improvements in birth outcomes. Federal welfare reform took place in 1996 and, as discussed above, replaced AFDC with TANF, leading to a reduction in funding and a shrinking role for cash assistance. A large body of literature examines the effects of welfare reform on short-term outcomes, such as maternal employment, family income, and health (Grogger and Karoly 2005; Moffitt 2003; Ziliak 2016). However, the evidence on the long-run effects of providing cash transfers to needy families and the long-term impact of welfare reform is limited. The best evidence we currently have on the effects of the welfare policies on children is from research syntheses that combine the data in several state welfare experiments in the years preceding federal welfare reform. For example, the results from research by Greg Duncan, Pamela Morris, and Chris Rodrigues (2011) imply that an additional $1,000 in family income increases student achievement by 0.05 to 0.06 standard deviation—a similar magnitude as the effects of the EITC described above.18 This achievement gain would be predicted to raise subsequent earnings by about 1 percent. 18.  These results come from pooling data across randomized experiments across U.S. states (and one from Canada), where one group received the welfare reform program and the other the preexisting AFDC program. The impact of income on child outcomes is identified using variation across different programs and an instrumental variables approach (the instrument is random assignment across states). HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 107 Before AFDC, some states operated cash welfare programs for families with children—termed “mothers’ pension” programs. Anna Aizer and others (2016) use unique historical data to evaluate the effect of child access to cash welfare on a wide range of long-term outcomes. The researchers digitize records from social service agencies in many states to determine who either applied for or received benefits, and they use a research design that compares children in families that were accepted into the program with children in families that were rejected. Using data from the military, death records, and several state historical censuses, they find that receipt of cash assistance has a host of positive effects, including reducing the probability of being underweight by half (the data are only available for men), increasing educational attainment by 0.4 year, and living an additional 1.5 years of life. There is suggestive evidence that the effects may be larger for children exposed at younger ages. Although this evidence, from more than 100 years ago, may have limited applicability to the benefits from current programs, it provides a unique and comprehensive set of findings measuring the impact of providing additional cash resources to dis­advantaged children over the very long run. An interesting set of studies sheds additional light on the impact of additional cash income to disadvantaged populations. Randall Akee and others (2010) trace the effects of a casino opening among the Eastern Band of Cherokee Indians in North Carolina. Using the casino revenues, the tribe initiated “per capita payments”—a sort of universal basic income provided to tribe members. Using variation across cohorts over time, compared with a geographically proximate control group, the researchers found that an additional $4,000 per year in income to the poorest households led to sizable improvements in educational attainment and a reduction in criminal activities, with no adverse impact on employment. Additionally, the cash transfer led to more parental investment and positive interactions between the parent and child, and beneficial effects on children’s emotional and behavioral health and personality traits during adolescence (Akee and others 2018). II.D.  Public Health Insurance: Medicaid Medicaid provides public health insurance to children (and others) in low-income families. Originally, only families receiving cash welfare were eligible for Medicaid, but federal law led to significant expansions in the 1980s and 1990s (Gruber 1997). Though states were required to meet particular expansion targets (for example, the Omnibus Budget Reconciliation Act of 1989 required states to cover pregnant women and 108 Brookings Papers on Economic Activity, Spring 2018 children under age 6 in families below 133 percent of the federal poverty level), the states took very different expansion paths—leading to variation in coverage across states, time, family income, and child age. A large body of literature takes advantage of these expansions, using differencein-differences models to investigate the long-run effects of access to health insurance and medical care. Another approach takes advantage of the fact that the Medicaid expansion legislation stipulated that states had to expand coverage only to children born after September 30, 1983, creating a sharp increase in Medicaid eligibility that is used in a regression discontinuity design. For example, poor children born in October 1983 experienced five more years of Medicaid eligibility compared with poor children born in September 1983 (Card and Shore-Sheppard 2004; Wherry and Meyer 2016). A few studies discussed below examine the introduction of Medicaid in 1965, which allows for investigation of the effects over a much longer period. Using the significant policy expansion in the 1980s and 1990s, work on the short-term effects of Medicaid eligibility found sizable effects on infant health, including reduced infant mortality and low birth weight (Currie and Gruber 1996). Infant health effects were stronger when expansions were restricted to low-income women, compared with broader expansions. By expanding eligibility and breaking its link to AFDC, the reforms also resulted in decreased AFDC participation and an increase in employment among affected mothers (Yelowitz 1995). A large body of literature has recently emerged that examines the effects of childhood exposure to Medicaid on health and economic outcomes in the teenage years through young adulthood. Currie and Hannes Schwandt (2016) find that during this period, mortality for infants and children declined overall, and inequality in mortality also fell (in contrast to the trends among older adults). Currie, Sandra Decker, and Wanchuan Lin (2008) find that Medicaid coverage in early childhood (age 2–4) leads to an improvement in self-reported health in later childhood. Laura Wherry and Meyer (2016) find that additional Medicaid in late childhood (age 8–14) leads to a 19 percent reduction in mortality rates from internal causes among blacks age 15–18. They do not find any significant mortality change among whites, or nonteenage blacks, although death rates for children older than 1 and younger than 15 are quite low. Additionally, Wherry and others (2018) find that Medicaid eligibility during childhood is associated with fewer hospitalizations and emergency room visits in early adulthood for blacks, with the largest reductions for visits related to chronic conditions and among individuals living in low-income neighborhoods. Miller and HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 109 Wherry (2018) find that Medicaid eligibility between conception and age 1 results in lower rates of chronic conditions and fewer hospitalizations related to diabetes and obesity in young adulthood. East and others (2017) find that Medicaid’s health benefits extend to the next generation: Children of mothers who had more exposure to Medicaid in their childhood themselves go on to have healthier infants. The positive effects of Medicaid are not limited to health outcomes. David Brown, Amanda Kowalski, and Ithai Lurie (2015) use administrative tax data and find that increased exposure to Medicaid during childhood increases education and earnings through age 28. Miller and Wherry (2018) find that expansions in Medicaid between conception and age 1 lead to increases in high school graduation. These results are also supported by Sarah Cohodes and others (2016), who find that increased Medicaid eligibility during childhood reduces high school dropout rates and increases college completion, and Phillip Levine and Schanzenbach (2009), who find it increases standardized test scores in fourth and eighth grade. Because these policy expansions have been relatively recent, the population of treated people is still in young adulthood. Examining the mid-1960s introduction of Medicaid allows for a longer-run evaluation of health insurance. Using the timing of the rollout of Medicaid across states, Michel Boudreaux, Ezra Golberstein, and Donna McAlpine (2016) find that increases in Medicaid exposure between birth and age 5 lead to reductions in chronic conditions (particularly high blood pressure) in adulthood. Using cross-state variation in AFDC rules and the introduction of Medicaid, Andrew Goodman-Bacon (2016) finds that additional childhood exposure reduces adult mortality and disability and increases adult employment. Overall, this recent research on Medicaid documents a strong link between greater access to public health insurance during childhood and improved health and economic well-being in adulthood. There is much more to learn, including the mechanisms for these improved long-run effects. II.E.  Implications of Safety Net Research Overall, the literature across programs finds positive long-run benefits of having access to safety net programs in childhood, leading to improvements to both health and economic productivity in adulthood. Before the emergence of this recent literature, the discussion of the costs and benefits of the social safety net was focused on the narrow lens of the short run. Many of the long-run benefits are private (such as improved own earnings 110 Brookings Papers on Economic Activity, Spring 2018 and own health), though public benefits are also present, due to increased taxes and decreased health-related government outlays. Although the literature does not suggest that the benefits “pay for themselves” in the long run, these programs nonetheless have substantial positive external benefits that have been quantified. Moreover, many additional aspects have not yet been quantified—for example, effects on criminal activity and longer-term effects on health—which have large public components and may further increase benefits. The literature points to findings that could be helpful in considering how to redesign the social safety net. First, in the limited number of cases that have explored differential returns by child age of exposure, the evidence points to greater long-run returns to exposure in early childhood than later childhood. Second, the benefits are larger for more disadvantaged groups, especially African Americans. One caveat of this finding, however, is that it can be difficult to disentangle whether the larger effects for more dis­ advantaged groups are due to higher rates of exposure to these programs or larger returns to exposure. Other dimensions—such as whether long-run returns differ across cash transfers, in-kind benefits, or health insurance— are important to ascertain; but the evidence is still too incomplete to be able to make such comparisons to inform better policy design. III.  The Recent Evolution of the Safety Net for Children Having summarized the recent findings documenting long-run benefits of childhood exposure to the social safety net, we now examine in more detail what population these core programs are serving and how this has changed over time. In particular, we use administrative data to examine aggregate trends in social safety net spending, how the spending varies across working and nonworking families, and how it varies across the income distribution. We do this for seven programs—Medicaid, EITC, CTC, SNAP, AFDC/TANF, SSI, and public housing—and our analysis covers the period 1990–2015. In light of the evidence presented in the previous section, not only may these trends have implications for the welfare of children, families, and the economy today, but they may also have an impact on individuals and the aggregate economy in the long run. The analysis of trends in safety net spending for different subgroups is complicated by the well-documented fact that social safety net income is increasingly underreported in household surveys (Meyer, Mok, and Sullivan 2009, 2015). Because this underreporting has increased over time, relying on household survey data may be particularly unsuitable for HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 111 examining trends in the social safety net. Therefore, our analysis relies as much as possible on program-specific administrative data.19 In general, we begin with administrative aggregates and identify the total spending on families with children. For programs that serve populations beyond families with children, we use available administrative data to identify the amount that goes to families with children.20 We then apportion total child spending into four groups based on the share going to those families with incomes less than 50 percent poverty, 50–99 percent poverty, 100–149 percent poverty, and 150–199 percent poverty.21 We also apportion total child spending into the amount going to families with earned income and families without earned income. Unlike the data given in figures 1 and 2 (which contain only federal data), our administrative aggregates for state and federal programs (AFDC/TANF and Medicaid) consist of the combined federal and state spending. To construct the spending across the four income-to-poverty bins requires a definition of family resources and the poverty threshold (a family is poor if resources are less than the poverty threshold). For the poverty threshold, we use the supplemental poverty measure (SPM), projected back to 1990 using methods developed by Christopher Wimer and others (2013). The SPM threshold bases needs on a broader array of necessary expenditures and makes other technical improvements relative to the official poverty measure (which is based on food costs alone). For reference, the SPM threshold for a family with two adults and two children in 2016 is $26,104, compared with $24,300 for the official poverty threshold. We 19.  Administrative data are not perfect. They are generated as part of program administration and as such often have limited demographic information and only capture family members and family resources that are part of eligibility and benefit determination. The advantage of household survey data is that they provide a more comprehensive picture of the household. 20. To be more specific, EITC, CTC, SNAP, TANF, and affordable housing provide benefits to “family units”—in our case, families with children. Two programs, Medicaid and SSI, provide benefits targeted to particular individuals. We count spending on the entire family (parents and children) for the family unit programs and count spending for the children for Medicaid and SSI. For more detail, see the online appendix; the online appendixes for this and all other papers in this volume may be found at the Brookings Papers web page, www.brookings.edu/bpea, under “Past BPEA Editions.” 21.  The CTC extends to families earning far above 200 percent of the federal poverty line—we estimate that almost 40 percent of the $54 billion in CTC spending in 2015 went to families above 200 percent of the federal poverty line. Among the other social safety net programs, little or no spending goes to families above 200 percent of the federal poverty line. To maintain our focus on programs targeting the low-income population, throughout our analysis in this section we limit CTC spending to families below 200 percent poverty. 112 Brookings Papers on Economic Activity, Spring 2018 define resources to be earned income plus cash transfers plus in-kind transfers (excluding Medicaid) minus taxes (but including the EITC and CTC)—essentially after-tax and transfer income, following Marianne Bitler and Hoynes (2016) and Bitler, Hoynes, and Elira Kuka (2017). This definition of resources is aligned with—though not identical to—the definition of resources in the SPM as measured by the U.S. Census Bureau since 2011.22 However, each administrative data source provides a different subset of these resource elements. We come as close as we can to measuring after-tax and transfer income consistently across the administrative data sources, imputing missing elements in some cases. Note that poverty is typically defined based on annual resources. Although the EITC and CTC measures contain annual income data, the administrative data for SNAP and AFDC/TANF only measure monthly income, which we then use to approximate annual income by multiplying by 12. We are able to apportion spending into the four poverty and two earnings groups, relying solely on administrative data for SNAP, EITC, CTC, and AFDC/TANF. For the remaining three programs (Medicaid, SSI, and public housing), no suitable administrative data are available; we instead use the Current Population Survey (CPS) to apportion aggregate spending into the groups. For more detail on our approach, see the online appendix. Figure 6 plots the real aggregate spending on families with children between 1990 and 2015, by program.23 Overall total spending is increasing, from under $100 billion in 1990 to about $270 billion in 2015 (in real 2015 dollars). However, the overall trend masks substantial differences across individual programs. Cash welfare (not tied to work) for families with children declined substantially after the 1996 federal welfare reform; cash assistance through AFDC totaled $34 billion in 1990, compared with $8 billion in 2015 under TANF. In contrast, the introduction of the CTC and expansion of both tax credits (EITC and CTC) have led to large increases 22.  The SPM resource measure subtracts medical out-of-pocket expenditures and workrelated expenses (including child care and other expenses). These elements are not measured in the administrative data and thus excluded from our resource measure. Additionally, each of our administrative data sources covers different income and transfer measures. For example, the tax data that we use for the EITC and CTC do not include any nontaxable income sources (such as SNAP); and the SNAP administrative data do not include measures of tax credits (such as the EITC and CTC). We make an effort to calculate resources consistently across sources; see the online appendix for details. 23.  Here, and throughout the rest of the paper, we limit CTC spending to that going to families with income below 200 percent of poverty. 113 HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH Figure 6.  Government Spending on Children, by Program, 1990–2015 Billions of 2015 dollars 250 200 Medicaid Public housing CTC EITC SNAP SSI AFDC/TANFa 150 100 50 1995 2000 Year 2005 2010 Sources: Various administrative sources (see the online appendix); authors’ calculations. a. AFDC became TANF after the 1996 welfare reform. in spending—from $12 billion in 1990 (for the EITC) to about $100 billion in 2015 for the combined EITC and CTC.24 SNAP spending had been fairly consistent during the first two decades of the time series, before increasing sharply during the Great Recession. Medicaid spending has also increased substantially during this 25-year period, reflecting the policy expansions that led to increases in health insurance coverage among children. Housing assistance and SSI, by contrast, have remained fairly small contributors to overall federal spending on children. In sum, the composition of the social safety net for children has changed substantially during this period. In 1990, the majority of spending was received by families with children receiving cash welfare.25 Today, there is minimal unconditional cash welfare spending; instead, the vast majority of public expenditures are for tax credits tied to paid work and health insurance. 24.  In 2015, the total CTC cost was $54 billion, and the cost limited to those with income below 200 percent of poverty was $33 billion. 25.  Before welfare reform, Medicaid was limited to families receiving cash assistance (AFDC or SSI). 114 Brookings Papers on Economic Activity, Spring 2018 To further investigate these changes, we next examine how social safety net spending has changed across the income distribution. To do this, we apportion total spending in each program into four bins of after-tax and transfer income relative to the SPM poverty threshold (less than 50 percent, 50–99 percent, 100–149 percent, 150–199 percent) and sum up across the programs. Figure 7 presents the tabulations based on spending on SNAP, EITC, CTC, and AFDC/TANF. We limit our analysis to these four programs because apportioning into poverty (and earnings) groups is possible using only administrative data. Online appendix figure 1 presents a comparable figure that also includes public housing, SSI, and Medicaid (where apportioning into groups relies on the CPS). In the top panel, we plot aggregate spending (by poverty category) over time in real 2015 dollars; and in the bottom panel, we plot the share of total spending each year going to each of the four poverty categories. These figures show that overall spending has increased most dramatically for families between 100 and 149 percent of the poverty line, from less than $10 billion in 1990 to $54 billion in 2015. Spending directed to families between 150 and 199 percent of poverty has also notably increased, from essentially $0 in 1990 to $14 billion in 2015. Spending on families between 50 and 99 percent of poverty dropped in real terms from 1995 to 2002, then increased sharply during the Great Recession before coming down again in recent years. The bottom panel shows that the share of the social safety net going to families with children living in poverty (particularly, 50–99 percent poverty) has declined substantially during this period; the share of spending on families with income below the poverty line has fallen, from 87 percent in 1990 to 56 percent in 2015. This has been replaced by gains in the share going to families with income at 100–149 percent poverty, and to a lesser extent those at 150–199 percent poverty. The qualitative findings are similar for the results on the full set of seven programs (online appendix figure 1). Although there are gains in the level of spending in each income-to-poverty group, the share of spending for families below the poverty threshold has fallen steeply. Another lens that can be used to examine this change is to apportion spending to families with earned income compared with families without earned income. We present those results (excluding Medicaid, SSI, and public housing) in figure 8 (and with these programs, in online appendix figure 2). These striking results show that virtually all the gains in spending on the social safety net for children since 1990 have gone to families with earnings (figure 8, top panel). In real terms, spending on families without earnings has fallen, from $45 billion in 1990 to $33 billion in 2015. The 115 HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH Figure 7.  Government Spending on Children, by Family Income, 1990–2015a Total spending Billions of 2015 dollars 60 50 to 99 percent 100 to 149 percent 40 Less than 50 percent 20 150 to 199 percent 1995 2000 2005 2010 Year Share of total spending Percent 60 50 to 99 percent 40 100 to 149 percent 20 Less than 50 percent 150 to 199 percent 1995 2000 2005 2010 Year Sources: Various administrative sources (see the online appendix); authors’ calculations. a. Programs include SNAP, AFDC/TANF, EITC, and CTC. The line captions denote family income as a percentage of the supplemental poverty measure. 116 Brookings Papers on Economic Activity, Spring 2018 Figure 8.  Government Spending on Children, by Parental Earnings, 1990–2015a Billions of 2015 dollars Total spending 120 Earnings 80 40 No earnings 1995 2000 2005 2010 Year Share of total spending Percent Earnings 80 60 40 No earnings 20 1995 2000 2005 2010 Year Sources: Various administrative sources (see the online appendix); authors’ calculations. a. Programs include SNAP, AFDC/TANF, EITC, and CTC. HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 117 share of total spending going to families without earnings has fallen even more—from almost 70 percent of spending in 1990 to 20 percent in 2015 (figure 8, bottom panel). The same patterns are evident for the full set of seven programs (online appendix figure 2). Figures 7 and 8 show that the distribution of spending has changed substantially over time—away from the lowest income levels and away from nonworkers. Part of this is the result of the contraction of some programs (for example, AFDC/TANF) and the expansion of others (EITC and CTC). Figure 9 provides a summary of the policy changes between 1992 (top panel) and 2015 (bottom panel). Each figure shows the sources of support for a hypothetical family consisting of a single mother with two children. We simulate the benefits for a range of annual earnings; all benefits and earnings are in 2015 dollars.26 In 1992, welfare reform had not yet occurred, the EITC was quite small, there was no CTC, and the benefits were targeted at the bottom of the earnings distribution. In 2015, in contrast, AFDC (now called TANF) is no longer an entitlement (so it is excluded from the figure), the EITC had expanded, the CTC had been introduced, and SNAP remained much the same. On net, resources shifted away from the lowest earnings levels and moved up the income distribution. These illustrative policy changes are borne out in the empirical analysis shown in figures 7 and 8. A natural question to ask is to what extent are the trends in spending across poverty and work categories (figures 7 and 8) driven by changes in the number of children across these groups. These changes may be a direct result of the changes in the policies illustrated above, as well as other factors. However, the administrative data do not allow for this measurement, so counting the number of children by poverty group (or by parental work status) requires using CPS data, which are known to contain substantial measurement errors. Nonetheless, figure 10 presents the percentage of children in each of the poverty groups, using CPS data from 1990 to 2015. The percentage of children below 50 percent of poverty has remained quite steady. The share in 50–99 percent poverty dropped sharply in the 1993–2000 period due to welfare reform, the EITC expansion, and the rise in employment (Meyer and Rosenbaum 2001; Grogger 2003), and slightly trended up before falling at the end of the period. We can use the poverty counts underlying figure 10 (and, for earnings, figure 4) and convert the spending in a poverty group (or earnings group) into spending per number of children in that group. 26.  These figures exclude income taxes paid. AFDC benefits are calculated under the rules of the state of Colorado. 118 Brookings Papers on Economic Activity, Spring 2018 Figure 9.  Tax and Transfer Benefits for Universally Available Cash and Near-Cash Programs for a Single Adult with Two Children in Colorado, 1992 and 2015 1992 2015 dollars SNAP CDCTCa CTC Dependent exemption AFDC EITC 12,000 9,000 6,000 3,000 50 100 150 200 250 Earnings as a percentage of the supplemental poverty measure threshold 2015 2015 dollars 12,000 9,000 6,000 3,000 50 100 150 200 250 Earnings as a percentage of the supplemental poverty measure threshold Sources: Steurle (2015), data provided by Caleb Quakenbush; Internal Revenue Service; Tax Policy Center; U.S. House of Representatives, Committee on Ways and Means, Green Book; U.S. Department of Agriculture; authors’ calculations. a. CDCTC stands for the Child and Dependent Care Tax Credit. 119 HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH Figure 10.  Percentage of Children in Supplemental Poverty Measure Bins, 1990–2015a Percent 100 to 149 percent 150 to 199 percent 15 10 50 to 99 percent 5 Less than 50 percent 1995 2000 2005 2010 Year Sources: Current Population Survey, Annual Social and Economic Supplement; authors’ calculations. a. The line captions denote family income as a percentage of the supplemental poverty measure. As shown in the top panel of figure 11, per-child spending in all the income-to-poverty groups exhibits a steady upward trajectory, particularly for the highest income-to-poverty groups—for example, from under $1,000 in 1990 to more than $4,000 in 2015 for those between 100 and 149 percent of poverty (in real 2015 dollars). The trends for the lower two groups are quite flat, by comparison, except for increases during the Great Recession and its aftermath. This is particularly apparent when the trends by poverty group are expressed relative to their 1990 levels. The bottom panel of figure 11 shows the relatively small changes for the lower poverty groups in per capita spending compared with the sixfold increase for those with incomes between 100 and 149 percent (in fact, we had to omit the relative trend for the highest income group because it increases 45 times over this period, from a very low baseline in 1990). As shown in figure 4, children are much more likely to live in families with working parents. This is important to take into account when viewing the trends over time in spending by earnings group (figure 8). Figure 12 presents per capita spending by earnings group in levels (top panel) and 120 Brookings Papers on Economic Activity, Spring 2018 Figure 11.  Per-Child Government Spending on Children, by Family Income, 1990–2015a Per-child spending 2015 dollars 50 to 99 percent 8,000 6,000 Less than 50 percent 4,000 100 to 149 percent 2,000 150 to 199 percent 1995 2000 2005 2010 Year Growth in per-child spendingb Index, 1990 = 1 6 100 to 149 percent 5 4 3 Less than 50 percent 2 1 50 to 99 percent 1995 2000 2005 2010 Year Sources: Various administrative sources (see the online appendix); authors’ calculations. a. Programs include SNAP, AFDC/TANF, EITC, and CTC. The line captions denote family income as a percentage of the supplemental poverty measure. b. The “150 to 199 percent” line is omitted from this panel due to its very high growth rate. (The value in 2015 relative to 1990 is 45.) 121 HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH Figure 12.  Per-Child Government Spending on Children, by Parental Earnings, 1990–2015a Per-child spending 2015 dollars 8,000 No earnings 6,000 4,000 2,000 Earnings 1995 2000 2005 2010 Year Growth in per-child spending Index, 1990 = 1 5 Earnings 4 3 2 1 No earnings 1995 2000 2005 2010 Year Sources: Various administrative sources (see the online appendix); authors’ calculations. a. Programs include SNAP, AFDC/TANF, EITC, and CTC. 122 Brookings Papers on Economic Activity, Spring 2018 Figure 13.  Government Spending on Children, by Poverty Status, 1990 and 2015a Billions of 2015 dollars Below 100 percent 100 percent and above 80 60 40 20 1990 2015 AFDC/TANF 1990 2015 CTC 1990 2015 SNAP 1990 2015 EITC 1990 2015 Medicaid Sources: Current Population Survey, Annual Social and Economic Supplement; various administrative sources (see the online appendix); authors’ calculations. a. The legend captions denote family income as a percentage of the supplemental poverty measure. relative to 1990 (bottom panel). These figures clearly show that the spending per child has increased dramatically for children in families with earnings (increasing fivefold over this period) compared with a small decline in per capita spending for children without working parents. To gain more insight into how these changes in the social safety net break down along the different programs, figure 13 presents spending for those below poverty (pooling less than 50 percent and 50–99 percent) and above poverty (pooling 100–149 percent and 150–199 percent) in 1990 and 2015, program by program. This figure reveals several important facts. Welfare reform and the decline in unconditional cash assistance are fully felt by those with the lowest incomes. More than half the increased spending for the EITC and more than three quarters of the increased spending for the CTC goes to those with incomes between 100 and 199 percent of poverty. Most of the increases in Medicaid spending are also going to those above poverty. Figure 14 shows that, across each program, the increases in spending are going to those with earned income. Ours is not the first study to examine the evolution of the social safety net for children and families. However, to our knowledge, we are the first 123 HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH Figure 14.  Government Spending on Children, by Parental Earnings, 1990 and 2015 Billions of 2015 dollars No earnings Earnings 80 60 40 20 1990 2015 AFDC/TANF 1990 2015 CTC 1990 2015 SNAP 1990 2015 EITC 1990 2015 Medicaid Sources: Current Population Survey, Annual Social and Economic Supplement; various administrative sources (see the online appendix); authors’ calculations. to rely almost exclusively on administrative data to analyze data by poverty status and work status. For example, Robert Moffitt (2015), in his presidential address to the Population Association of America, presents similar calculations by poverty status when he uses the Survey of Income and Program Participation to apportion spending into poverty bins. The Congressional Budget Office (2013), in its analysis of the distribution of taxes and spending across income quintiles, uses the Internal Revenue Service’s Statistics of Income Public Use File (for taxable transfers, EITC, CTC, and other taxes—as we do) but uses the CPS for nontaxable transfers. Meyer and Nikolas Mittag (2015) show that relying on household surveys such as the CPS entails important misclassifications of the level and composition of families defined as poor. Isaacs and others (2017) use the Urban Institute’s Transfer Income Model to adjust for underreporting of transfers, but their study focuses on aggregate trends and does not show the results by poverty or work status. In online appendix figure 3, we compare the CPS and administrative estimates of the share of social safety net spending by poverty group. The CPS shows much higher amounts of spending on the above-poverty group than do the administrative data, which is consistent with underreporting among lower-income survey recipients. The CPS 124 Brookings Papers on Economic Activity, Spring 2018 underreporting is also becoming greater over time for the below-poverty group—the ratio of CPS to administrative counts fell from almost 50 percent in 1990 to 27 percent in 2015. In summary, the level and composition of the social safety net for families with children has changed substantially over the past 25 years. One major finding is the decline of cash assistance and the rise of Medicaid and tax credits that are linked to paid work. Spending on Medicaid and tax credits has grown, both absolutely and as a share of total expenditures, and they now represent three quarters of all spending on low income families with children. A second major finding is the shift in spending to workcontingent programs away from traditional out-of-work assistance. A third finding, related to the first two, is the shift in spending from the most disadvantaged to somewhat higher up the income distribution. Finally, throughout this period, SNAP has remained steady and significantly important for low-income families. An implication of this shift is less protection from negative (labor market and other) shocks among disadvantaged families. In fact, building a safety net around work leaves families with little protection during times of high unemployment. Bitler, Hoynes, and Kuka (2017) show that spending on tax credits is procyclical, and thus provides little protection against economic downturns. Bitler and Hoynes (2015, 2016) show that an implication of the massive shift in the social safety net is that deep poverty increased by more during the Great Recession than one would have predicted from previous downturns.27 This shift would also be expected to increase income volatility for the most disadvantaged. Because unemployment rates are higher and more cyclical for African Americans, this reorientation of the safety net is likely to have particularly harmful consequences for black children (Hoynes, Miller, and Schaller 2012). The mounting evidence presented above on the long-term effects of resources in childhood, however, suggests that children’s additional vulnerability to economic downturns likely will have downstream costs in terms of worse later-life health and economic outcomes. 27.  Bitler and Hoynes’s work estimates regressions of the relationship between the state-level unemployment rate and poverty and deep poverty rates, finding that in the Great Recession deep poverty increased by more than would be predicted based on the relationship from previous recessions. Bitler and Hoynes’s data are not adjusted for underreporting. Sherman and Trisi (2015) find that the overall rate of children’s deep poverty, after adjusting for underreporting, did not rise between 2007 (2.7 percent) and 2010 (2.6 percent). HILARY W. HOYNES and DIANE WHITMORE SCHANZENBACH 125 IV.  Conclusions and Future Research Increasing income and resources at the bottom of the distribution may generate substantial benefits, both private and public, in the longer run that have only recently begun to be quantified. There may be particularly large returns to these investments when children are young and to the most disadvantaged children. This implies that the benefits of the safety net are broader than previously thought, and that there are positive external benefits for taxpayers. With interest in more “evidence-based policymaking,” it is important to keep in mind that the costs are easily measured today, but many of the benefits are harder to measure and may not appear for many years. There is much more we would like to know. There are more outcomes to be quantified—including outcomes that, if improved, would yield substantial public cost savings, such as disability, crime, and later-life health. There are programs with demonstrated positive, short-run effects (for example, WIC and SSI) where we have no research on long-run effects. In addition, it is important to determine whether there are interactions between programs and, if so, whether they are substitutes or complements. What is effective for remediation for early childhood deprivation? How do these investments vary across children? When and for whom are the benefits the greatest? Are the returns consistently greater in early life? Are there differences by gender or race? Finally, we need to fill in gaps in our understanding of the effects of programs between early life and adulthood; this should help us learn about mechanisms. Given the early stages of this research, we do not think it is possible at this point to draw conclusions about the rates of return, their magnitudes, or how they vary across different programs. Given the emerging evidence, we do not think it is likely that these long-run benefits will be sufficiently large for the programs to “pay for themselves.” However, these long-run benefits currently are largely ignored in policy discussions, but they may be important for gaining insight into the nature of material deprivation and the gains from a more generous and countercyclical social safety net. The research has been sufficiently developed, however, to provide some guidance for policymakers. First, it documents the importance of a robust social safety net. Cuts to programs that reduce resources going to children, which are currently being discussed, will have direct, negative effects on children in both the short and long terms. Second, employment and earnings have become an increasingly important source of income for the poor, and as a result safety net programs are acting as a partial income supplement 126 Brookings Papers on Economic Activity, Spring 2018 during normal economic times (which is extremely important, given the prevalence of wage stagnation in the lower half of the wage distribution), and are acting as consumption insurance when earnings are lost or fewer hours are available. As such, it is crucial to preserve these programs’ work incentives, which are currently quite strong (Kosar and Moffitt 2017), and also to ensure that these programs can respond quickly to replace lost income during recessions. This suggests that reforms such as block grants that are unchanged during downturns—or require congressional approval, and the delays that come with it—are less effective than programs that can automatically respond and quickly enroll families once they become eligible for benefits. Third, given the long-run benefits of these programs, more effort should be paid to enrolling all eligible children. Fourth, building a safety net based largely on work-contingent programs means that they provide incomplete insurance against earnings and employment losses. The fact that the United States lacks a significant out-of-work social safety net means higher rates of deep poverty (below 50 percent poverty), which harms children in both the short and long runs. To put this all together, because safety net spending has a substantial investment component, and because there have been positive returns from expansions in spending, the evidence suggests that we may be spending too little on the safety net for the young. ACKNOWLEDGMENTS   We thank Janet Currie, Gordon Dahl, Robert Doar, Janice Eberly, Ryan Nunn, Dottie Rosenbaum, Louise Sheiner, Arloc Sherman, James Stock, and participants in the Spring 2018 Brookings Panel on Economic Activity for helpful comments. 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Wimer, Christopher, Liana Fox, Irv Garfinkel, Neeraj Kaushal, and Jane Waldfogel. 2013. “Trends in Poverty with an Anchored Supplemental Poverty Measure.” Working Paper no. 13-01. New York: Columbia Population Research Center. Yelowitz, Aaron S. 1995. “The Medicaid Notch, Labor Supply, and Welfare Participation: Evidence from Eligibility Expansions.” Quarterly Journal of Economics 110, no. 4: 909–39. Ziliak, James P. 2016. “Temporary Assistance for Needy Families.” In Economics of Means-Tested Transfer Programs in the United States, Volume I, edited by Robert A. Moffitt. University of Chicago Press. Comments and Discussion COMMENT BY JANET CURRIE   This paper by Hilary Hoynes and Diane Schanzenbach should be required reading for policymakers facing decisions about social safety net programs in the United States. The bottom line is clear, and clearly put: We are spending too little on children and their families. . . . Any cuts to current programs that will reduce resources going to children would have direct, negative effects on children in both the short and long terms. It is also crucial to recognize that the modal recipient family is combining safety net use with employment; the view that all spending is welfare and going to out-of-work families is not the case. The findings regarding spending, in particular, are the most authoritative to date in that they are based on administrative data, which captures much more spending on families at the bottom of the income distribution than traditional, survey-based measures. Hoynes and Schanzenbach argue that we spend too little, because society has not recognized the returns to investing in safety net programs in terms of reductions in taxpayer expenditures (or increases in tax revenues) down the road. Children who grow up to be better educated, more likely to be employed, and more likely to lead healthy and productive lives will pay higher taxes themselves and be less likely to rely on taxpayer-funded social programs as they age. Although there is no doubt that safety net programs have an investment component, it is less clear that policymakers have failed to take future payoffs into account when arriving at current levels of social spending. Language about “investing in children” goes back at least to the Clinton administration. President Clinton’s 2000 State of the Union Address repeatedly calls for investing in children and working families—stating, for example, “We must also make investments that 133 134 Brookings Papers on Economic Activity, Spring 2018 reward work and support families. Nothing does that better than the Earned Income Tax Credit.” It is possible, in fact, that policymakers have taken the investment paradigm too literally when it comes to children. As Hoynes and Schanzenbach point out, the United States spends 2.1 percent of GDP on children, compared with 9 percent of GDP on the elderly. Yet we do not expect spending on the elderly to yield a return. We spend on the elderly because they are viewed as deserving of our support. The disparity in treatment of children and the elderly is embedded in the fact that programs for the elderly (especially Social Security and Medicare) are entitlements, with strong protection from the vagaries of federal budgeting, whereas programs for children are highly vulnerable to cuts in spending from their alreadylow levels. Although the comparison between spending on children and spending on the elderly is instructive, focusing on intergenerational conflict may distract from the major driver of spending, which is health care costs. Hoynes and Schanzenbach’s figure 6 shows that Medicaid is the largest single program for children in terms of costs, and this figure understates costs because it omits spending on pregnant women and the state Child Health Insurance Program (CHIP). Moreover, in programs such as public housing and the Supplemental Nutritional Assistance Program (SNAP), some share of the benefit goes to adults in the household, whereas Medicaid is targeted to the covered children. However, the bulk of public health care spending goes to the elderly and disabled. Until recently, Medicaid itself was really two programs, one covering low-income children and their parents, and the other covering the elderly and disabled. And though children make up half of Medicaid beneficiaries, they account for only 19 percent of expenditures (Truffer, Wolfe, and Rennie 2016). In 2015, per-person personal health care spending for the elderly, disabled, and children was, respectively, $14,323, $19,478, and $3,389.1 Now that substantial numbers of adults are also covered under the Affordable Care Act’s Medicaid expansions, the share of Medicaid spending accounted for by low-income children can be expected to fall still further. Given the gap in health care costs between children and the elderly, rising health care costs can be expected to widen gaps in spending between 1.  This is according to the Centers for Medicare and Medicaid Services’ National Health Expenditures fact sheet for 2015. COMMENTS and DISCUSSION 135 the two groups and will create budgetary pressures that will threaten all other forms of spending on children. According to the Centers for Medicare and Medicaid Services, health care spending has been growing faster than the rate of inflation for decades, and is projected to continue to do so. This rise in health care costs seems to be driven largely by higher prices in the United States relative to other countries. Preserving the safety net is likely to require the reining in of health care costs. Because prices are so important to driving costs, measures that might help include imposing regulations to mandate price transparency and reforming Medicare to allow it to negotiate prices (including drug prices) with providers. Other measures that might help include using big data to identify providers that are outliers in the care they provide, and more systematically identifying best practices (Currie, MacLeod, and Van Parys 2016; Currie and MacLeod 2017). Just as rising health care costs will continue to drive a wedge between spending on the elderly and spending on children, they will also continue to increase the share of spending on children in families just above the poverty line relative to children in poor families. This shift in relative spending is quite intentional. Even if we kept everything the same for poor families, expanding public health insurance for families above the poverty line (along with expansions of the Earned Income Tax Credit and other programs to families in this income category) would have had the effect of increasing the share of safety net spending going to families above the poverty threshold. Hence, I urge readers not to skip the authors’ online appendix, and to focus on the figures that show amounts spent per child in the various income categories (for example, the top panels of the authors’ figures 11 and 12), rather than to focus on the figures emphasizing expenditure shares for different economic groups. These figures also suggest flat periods in spending on families below poverty, along with declines in spending for families with no income between 1995 and 2005, but are less dramatic than the shifts in shares emphasized in the main text. On the whole, they indicate that the trend is for new safety net monies to be allocated to nearly poor families rather than for money to have been taken from poor families. Hoynes and Schanzenbach focus on federal spending, but it is important to understand that this is only one strand of the safety net. State and local spending on the safety net is tremendously important, and also highly variable across states and over time. Medicaid is one of the most important components of state budgets (along with K–12 education, higher education, and prisons), so rising health care costs threaten to eat up a larger and 136 Brookings Papers on Economic Activity, Spring 2018 larger share of state spending. This budgetary pressure will likely have negative consequences for public education, state Earned Income Tax Credit programs and child tax credits, and child protective services (which are chronically underfunded in many localities, even though child abuse and neglect is a leading cause of child injury and death). Other important state programs to protect working families include workers’ compensation and especially unemployment insurance. It is surprising that in a period when the safety net is increasingly geared toward parents who work, unemployment insurance systems in many states have become less and less generous, to the point where they offer very little insurance to working families in the event of a job loss. Data from the National Employment Law Project indicate that the fraction of the unemployed who receive any assistance ranges from a low of 11 percent in Florida to a high of 66 percent in North Dakota. The median state, Oklahoma, assisted only 28 percent of the unemployed (McKenna and McHugh 2016). Several states adopted significant benefit cuts after 2011, and currently nine states are offering fewer than 26 weeks of benefits. For example, in Florida in February 2016, a newly unemployed worker qualified for only 12 weeks of benefits. Given work by Jonathan Gruber (1997) and Raj Chetty (2008) showing that unemployment insurance smooths consumption and reduces liquidity constraints on households, this is a disturbing trend. One reason that state and local safety net programs are generally neglected by researchers, despite the rich variation in these programs, is that good data are hard to come by. Even for federal programs, administrative data are patchy and incomplete. For example, Hoynes and Schanzenbach point out that there are no federal data that can be used to apportion Medicaid, Supplemental Security Income, and public housing expenditures by poverty group or parental employment status. Hence, even studying the components of the federal safety net in a consistent fashion requires making assumptions about how resources are being allocated. The researcher wishing to study state and local programs must first assemble and harmonize data from many different jurisdictions, all with different data access policies and stances toward the use of their administrative data for research purposes. Thus, just building a data set becomes simply a monumental task that tends to shut down research before it can even get started. The creation of cross-state data depositories for state and local administrative data would likely have a tremendous impact on research in this area. One model is the Healthcare Cost and Utilization Project, which is managed under the auspices of the federal Agency for COMMENTS and DISCUSSION 137 Healthcare Research and Quality. Participating states provide their hospital discharge data (that is, records of each hospitalization that occurs in the state, which are collected for regulatory purposes) to the project’s central depository, which makes the data available in an anonymous and standardized format to health care researchers. One reason to hope that more data could become available at the state and local levels is that these jurisdictions will be increasingly responsible for experimenting with the traditional safety net programs. Executive Order 13828, dated April 10, 2018, encourages states to implement stricter work requirements on programs, including SNAP and Medicaid, reduce the size of program bureaucracies, target programs more strictly to the neediest people, and eliminate programs they find to be duplicative or ineffective. It also promises to grant states flexibility to achieve these goals. These policies seem likely to reduce access to the safety net for many, and it will be important to assess their effects on children and families. In summary, Hoynes and Schanzenbach offer a wonderful introduction and overview to federal safety net programs, as well as innovative analyses of administrative data to support their arguments. In this brief comment, I have tried to place the programs and trends they identify in a larger context, in which spending on the elderly is protected in entitlement programs while spending on children is not; spending on all nonhealth programs is increasingly threatened by rising health care costs; and variation in the generosity of the safety net depends on state and local policies, in addition to the federal programs and policies that garner the lion’s share of research attention. Adding these dimensions to the analysis would not change their key conclusion—that we spend too little on children—but it would make clear how difficult it may be to spend more on programs that have been shown to make a difference. REFERENCES FOR THE CURRIE COMMENT Chetty, Raj. 2008. “Moral Hazard versus Liquidity and Optimal Unemployment Insurance.” Journal of Political Economy 116, no. 2: 173–234. Currie, Janet, and W. Bentley MacLeod. 2017. “Diagnosing Expertise: Human Capital, Decision Making and Performance among Physicians.” Journal of Labor Economics 35, no. 1: 1–43. Currie, Janet, W. Bentley MacLeod, and Jessica Van Parys. 2016. “Provider Practice Style and Patient Health Outcomes: The Case of Heart Attacks.” Journal of Health Economics 47: 64–80. Gruber, Jonathan. 1997. “The Consumption Smoothing Benefits of Unemployment Insurance.” American Economic Review 87, no. 1: 192–205. 138 Brookings Papers on Economic Activity, Spring 2018 McKenna, Claire, and Rick McHugh. 2016. “Share of Unemployed Receiving Jobless Aid Remained at Record Low in 2015.” Blog post, February 9, National Employment Law Project, New York. Truffer, Christopher J., Christian J. Wolfe, and Kathryn E. Rennie. 2016. 2016 Actuarial Report on the Financial Outlook for Medicaid. Baltimore: Centers for Medicare and Medicaid Services. COMMENT BY GORDON B. DAHL1   Hilary Hoynes and Diane Schanzenbach’s paper serves as a valuable resource for both researchers and policymakers. It makes two contributions. First, it synthesizes the recent literature on the effects of early investments in children, with a particular focus on safety net spending directed toward children. Not so many years ago, there was scant evidence on long-term outcomes, and arguments for government transfer spending on children relied more on humanitarian and social insurance grounds. But as Hoynes and Schanzenbach document, there is now substantial evidence that spending on children has benefits for a variety of later-in-life outcomes. Some of these gains accrue privately, but others have positive spillovers to society due to increased tax revenue and lower government transfers in the future. The second contribution is an analysis of how spending on children via the safety net has changed over time. The findings are both striking and relevant for policymaking. Total spending has remained fairly flat over time, but its composition has changed. Relative to 20 years ago, more spending reaches families near or above the poverty line, while less is spent on the poorest of the poor. There has also been a large movement away from unconditional transfers and toward benefits linked to work. Other studies have looked at how the child safety net has evolved, but this is the first based primarily on administrative data. This is an important contribution, given that survey data suffer from several issues—including sizable undercounting, a problem that is becoming more severe over time. Although the long-term benefits of safety net spending on children documented by Hoynes and Schanzenbach are compelling and broadbased, I found it refreshing that the authors remained true to what the data can and cannot say in terms of policy recommendations. The authors rightly conclude that the fiscal benefits are unlikely to make increased expenditures on child safety net programs self-funding. Instead, the investment 1.  I am grateful to my colleagues Jeff Clemens, Julie Cullen, and Roger Gordon for helpful discussions and suggestions. COMMENTS and DISCUSSION 139 rationale still needs to be combined with humanitarian and social insurance motivations. Moreover, the authors recognize that the literature is not yet developed enough to estimate rates of return or provide guidance on how to optimally allocate funding across programs. This type of humility is admirable, but it should not detract from the authors’ main policy conclusion that there is “a substantial investment component [to safety net spending], and because there have been positive returns from expansions in spending, the evidence suggests that we may be spending too little on the safety net for the young.” At a more granular level, there is a solid case that returns to increased spending on children are especially large for the most dis­ advantaged, and that reallocating spending from later in life to earlier in life is likely to enhance efficiency. Hoynes and Schanzenbach are experts on this topic. Their summary of the literature is comprehensive and up-to-date, and their analysis of spending trends is well executed. This is a great paper, with little to quibble over, so I instead focus my comments on three broadly related issues: program interactions, work requirements, and intergenerational issues. PROGRAM INTERACTIONS The authors’ analysis focuses on the tax and transfer benefits for seven of the largest programs affecting children. In the authors’ figure 9, they summarize changes in universally available cash and near-cash programs between 1992 and 2015. The figure plots benefits for a single adult with two children in Colorado, and serves to highlight the shift over time toward programs tied to work. An augmented version of the authors’ figure 9 can also be used to illustrate program interactions, and the unintended incentives that can arise. In my figure 1, I have added three universally available noncash programs to the 2015 panel: Medicaid, the Children’s Health Insurance Program (CHIP), and the Premium Tax Credit (PTC), which subsidizes health insurance under the Affordable Care Act (ACA). These three programs provide a patchwork of health insurance coverage for low-income families. As background, all but two states cover children’s health insurance up to at least 200 percent of the federal poverty level (FPL) via Medicaid coverage and CHIP. In addition, most states cover pregnant women past the federal minimum of 138 percent of the FPL via Medicaid and CHIP. In contrast, health insurance coverage for other parents varies widely across states. Thirty-two states currently cover parents up to 138 percent of the FPL, because these states have adopted the ACA Medicaid expansions. But 19 states have not expanded Medicaid, and among these nonexpansion states, the median eligibility limit is only 44 percent of the FPL. Premium assistance credits kick in after 138 percent of the FPL has been reached for 140 Brookings Papers on Economic Activity, Spring 2018 Figure 1.  Tax and Transfer Benefits for Universally Available Cash, Near-Cash, and Noncash Programs for a Single Adult with Two Children in North Carolina, 2015 2015 dollars 20,000 15,000 PTCa CHIP Medicaidb SNAP CDCTCc CTCd Dependent exemption EITC 10,000 5,000 100 200 300 400 Earnings as a percentage of the federal poverty line Sources: Hoynes and Schanzenbach, top panel of figure 9; HealthCare.gov; Kaiser Family Foundation; author’s calculations. a. The PTC area above CHIP includes parents only. The PTC area to the right of CHIP includes parents and children. b. Medicaid includes parents and children. c. CDCTC stands for the Child and Dependent Care Tax Credit. d. CTC stands for the Child Tax Credit. all parents, and after CHIP eligibility ends for all children (Garfield and Damico 2017). In my figure 1, I graph the case for a single adult with two children in North Carolina (as opposed to Colorado, in the authors’ figure 9).2 North Carolina was chosen because it illustrates the potential for perverse work incentives when the three health insurance programs are not well coordinated. North Carolina chose not to adopt the Medicaid expansions. Between 0 and 44 percent of the FPL, a parent in North Carolina qualifies for Medicaid; between 44 and 138 percent, a parent receives no coverage or subsidy; and between 138 and roughly 350 percent, a parent is eligible 2.  Thanks to Hoynes and Schanzenbach for sharing their figure 9 with me. Program parameters for the Medicaid, CHIP, and PTC programs come from HealthCare.gov and the Kaiser Family Foundation. COMMENTS and DISCUSSION 141 for marketplace subsidies through the PTC. This creates a gap in coverage for the parent, as shown in my figure 1. To illustrate the type of work disincentives created by the canyon-shaped gap in coverage, consider a single parent in North Carolina with two children who earns the minimum wage of $7.25 per hour. If this parent works between 0 and 25 hours per week ($0 and $8,985 in yearly earnings), they would be covered by Medicaid. But they would have no coverage if they worked between 25 and 78 hours per week, as marketplace subsidies do not start until $28,180 per year. This example makes clear the disincentive for full-time employment, as it entails a loss of Medicaid. Even for a single parent making twice the minimum wage ($14.50 per hour), there would be no assistance between 12 and 39 hours per week. Does the ACA mandate that employers offer full-time workers health insurance coverage help fill in the gap? The answer is: only imperfectly. One challenge is that such a mandate creates an employer-based disincentive for hiring full-time workers. Moreover, 42 percent of working adult Medicaid enrollees work in a firm with fewer than 50 employees, and these firms are exempt from the mandate (Garfield, Rudowitz, and Damico 2018). As shown in my figure 1, health insurance assistance for children does not have a similar gap. Even so, a parent’s coverage can have spillovers to their children. The first reason is that when a parent does not have access to health care, they are more likely to become sick and less able to effectively care for their children. An additional spillover is that roughly 160,000 uninsured children have a parent in the coverage gap. This is potentially a problem, because parental coverage in public programs is associated with higher enrollment of eligible children (Sommers 2006). Similar notches in the Temporary Assistance to Needy Families (TANF) program and Section 8 housing vouchers make the work disincentive problem even worse for some families. Other programs—such as the Special Supplemental Nutrition Program for Women, Infants, and Children and the National School Lunch Program—are also tied to the FPL, and therefore they affect a family’s budget constraint. One caveat in the analysis of noncash programs is that individuals may not value them at the cost of provision.3 If individuals value in-kind transfers such as health insurance or housing vouchers at less than their cost, this would make the canyonshaped gaps in the budget constraint less pronounced. But the basic point 3. For example, Finkelstein, Hendren, and Luttmer (2015) find individuals value Medicaid benefits between $0.20 and $0.40 per $1 of government spending, perhaps in part because the counterfactual is often not a complete lack of medical care but care from other sources, such as emergency rooms. 142 Brookings Papers on Economic Activity, Spring 2018 remains that program interactions can have unintended incentive effects, especially when they create nonlinearities and dominate segments in the budget constraint. As a side note, from an evaluation perspective, program interactions make it more difficult to estimate the effect of safety net programs. Programs can have offsetting incentive effects on an individual’s budget constraint. For example, the phase-out portion of the Earned Income Tax Credit (EITC) coincides with the introduction of health insurance subsidies in my figure 1. Program interactions also pose a challenge for certain estimation approaches. Suppose a researcher was interested in utilizing the kinks in the EITC schedule to estimate labor supply elasticities. One approach would be to use a bunching estimator, looking for excess mass to the left of the first kink in the EITC schedule, for example. But my figure 1 makes clear that in this setting a bunching estimator will have issues, as the notch in Medicaid will limit the number of individuals with earnings in a neighborhood near the first EITC kink. WORK REQUIREMENTS  One of Hoynes and Schanzenbach’s central findings is that there has been a shift toward requiring work for benefit eligibility, largely as a result of more reliance on programs like the EITC and less on cash transfers like the now-defunct Aid to Families with Dependent Children program. The authors recognize the importance of assistance programs that supplement low earnings during normal economic times, especially given wage stagnation in the lower end of the wage distribution. They argue that “it is crucial to preserve these programs’ work incentives, which are currently quite strong.” Preserving work incentives is important, but the shift toward work requirements can have the wrong incentives if implementation is not well thought out. Consider recent proposals to link Medicaid to employment. Starting in January 2018, states were allowed to seek a waiver and impose work requirements for Medicaid eligibility. Kentucky was the first state to get approval, and other states are following (Goldstein 2018). For Medicaid nonexpansion states seeking waivers, like Kansas and Mississippi, meeting Medicaid work requirements through 20 hours of work at the minimum wage would actually lead to a loss of Medicaid eligibility, as income would be too high. One solution is to expand Medicaid coverage at the same time as imposing a work requirement, a proposal that was recently put forward as a political compromise in North Carolina.4 4.  Although work requirements are generally waived for caregivers of young children, a work requirement would still affect a couple’s work incentives. COMMENTS and DISCUSSION 143 Moreover, it is important to recognize that not all social assistance programs are designed with a positive work incentive. Consider one of the largest social insurance programs in most countries, disability insurance (DI). In the United States, DI is administered through two programs, Supplemental Security Income and Social Security Disability Insurance. To qualify for DI in the United States, the primary requirement is that the individual is deemed not able to work, with individuals being disqualified if they earn more than a minimal amount.5 DI is often considered a social insurance program, but it also has incentive effects and is a key part of the safety net. DI participation has been shown to generally rise during periods of high unemployment, even though it is unlikely that the latent amount of disability in the population has increased (Autor and Duggan 2003). In the United States, an individual is either on or off DI, whereas in many European countries partial disability is allowed. For example, in the Netherlands roughly 40 percent of individuals are currently on partial disability benefits. One possible reform to the U.S. system would be to allow for partial disability, so that individuals with some ability to work could be gainfully employed. Research finds that many DI participants have substantial work capacity, both in the United States and Europe (French and Song 2014; Maestas, Mullen, and Strand 2013; Kostøl and Mogstad 2014). The possibility of partial DI has the potential for cost savings that can be redirected elsewhere. A detailed discussion of policy reforms to encourage part-time work for disabled individuals is beyond the scope of this comment. But other researchers have thoughtfully considered what types of reforms might work. Some of the more innovative proposals promote work through a mixture of firm incentives and individual accommodations to allow those with partial work limitations to remain employed or return to work (Autor and Duggan 2010; Burkhauser and Daly 2012). How do DI programs interact with the rest of the social safety net provided to families? The first thing to note is that health insurance coverage is automatic if an individual is on DI in the United States. Combined with a replacement rate of 40 to 50 percent, this makes DI one of the more generous social assistance programs in the United States. 5.  There are some existing incentives for participants to exit DI and return to work. For example, participants can earn more money during a “trial work period” for Social Security Disability Insurance, but not Supplemental Security Income. Moreover, programs like the Social Security Ticket to Work program provide resources such as vocational training. 144 Brookings Papers on Economic Activity, Spring 2018 Recent research has also documented substantial social support substitution across programs. Lex Borghans, Anne Gielen, and Erzo Luttmer (2014) examine a reform in the Netherlands that tightened DI eligibility for existing claimants. Using a regression discontinuity design, they find that about 4 percent of DI participants exited DI due to the more stringent rules and that annual benefits fell by about €1,000, or roughly 10 percent. Treated individuals exposed to the reform replaced over 60 percent of lost DI benefits with increased earnings in the labor market. Equally relevant, the drop in DI income was partly offset as individuals shifted to other government programs. The authors find that for each €1 of lost DI benefits, treated individuals collected €0.30 from other social assistance programs in the short run (primarily unemployment insurance). This echoes the point made above that considering program interactions is crucial when evaluating the social safety net. INTERGENERATIONAL ISSUES  Hoynes and Schanzenbach’s review of the recent literature documents compelling evidence for the positive effects of social safety net spending on children’s outcomes. There are both immediate and medium-term benefits, as well as long-term improvements in a variety of health, human capital, and economic outcomes. When thinking about long-term effects, one additional consideration is whether a parent’s participation in a program has an effect on their child’s participation. Parental participation in a social assistance program—such as TANF, SNAP, or DI—could influence a child’s participation through a variety of channels. Parents could serve as role models, provide information about how to apply, demonstrate what it is like to be on a program, or even invest differentially in child development due to changing resource constraints. All these channels suggest a causal effect, where a parent’s participation influences a child’s outcomes in the long run. Conversely, the use of public assistance could primarily be due to environmental factors. Poverty, bad health, and reduced opportunities could persist across generations, in which case intergenerational links could simply reflect unobserved heterogeneity and not a behavioral response. Until recently, it has been difficult to differentiate between correlation and causation. But a series of recent quasi-experimental papers suggests that children do learn from their parents. For example, using an instrumental variables approach, Robert Hartley, Carlos Lamarche, and James Ziliak (2017) find that a mother’s use of welfare increases the chances that her daughter will participate as well. Using a random judge design, Dahl, Andreas Kostøl, and Magne Mogstad (2014) find that children whose COMMENTS and DISCUSSION 145 parents enter DI on appeal are more likely to themselves participate as young adults. And using a regression discontinuity design, Dahl and Gielen (2018) find that children whose parents are kicked off DI or have their benefits reduced are less likely to themselves participate 21 years later. Monique de Hann and Ragnhild Schreiner (2017) bound average treatment effects and find substantially smaller estimates compared with the local average treatment effects identified in the other papers, suggesting caution about extrapolating the large responses found to the entire population. Taken together, these recent studies suggest that children do learn from and copy their parents. But the spillovers extend beyond program participation. Dahl and Gielen (2018) show that children whose parents are pushed out of DI or have their benefits reduced not only reduce their own participation in DI but also earn more in the labor market as adults. The increased taxes due to increased earnings by children exceed the cost savings from their reduced DI usage. Consistent with an anticipated future with less reliance on DI, the children of affected parents on average complete an extra 0.12 year of schooling. Although several interpretations of these intergenerational effects are possible, a consistent explanation is that children learn from their parents about the relative costs, benefits, and stigma associated with work versus government assistance. From a fiscal perspective, these intergenerational links matter. Ignoring parent-to-child spillovers understates the long-run cost savings of the Dutch reform by between 21 and 40 percent in present discounted value terms. FINAL THOUGHTS  Hoynes and Schanzenbach provide an excellent summary of the existing literature and a careful analysis of safety net investments in children. Their paper is a useful reference for academic researchers and policymakers alike. Though my comment has disproportionately focused on various aspects of incentives related to work, this should not be interpreted as an endorsement of policies to reduce or eliminate unconditional cash transfers. As the authors point out, “building a safety net around work leaves families with little protection during times of high unemployment.” Creating effective incentives for work is important, but it is crucial to recognize that the social safety net also needs to take care of children with nonworking parents. Children whose parents are out of work are among the poorest of the poor, and the United States currently does not have a com­ prehensive safety net to cover them. Investments in these disadvantaged children have high returns, but policy recommendations about how to best structure programs to help children in these nonworking families are beyond the scope of this comment. 146 Brookings Papers on Economic Activity, Spring 2018 REFERENCES FOR THE DAHL COMMENT Autor, David H., and Mark G. Duggan. 2003. “The Rise in the Disability Rolls and the Decline in Unemployment.” Quarterly Journal of Economics 118, no. 1: 157–206. ———. 2010. “Supporting Work: A Proposal for Modernizing the U.S. Disability Insurance System.” Washington: Center for American Progress and Hamilton Project. Borghans, Lex, Anne C. Gielen, and Erzo F. P. Luttmer. 2014. “Social Support Substitution and the Earnings Rebound: Evidence from a Regression Discontinuity in Disability Insurance Reform.” American Economic Journal: Economic Policy 6, no. 4: 34–70. Burkhauser, Richard V., and Mary C. Daly. 2012. “Social Security Disability Insurance: Time for Fundamental Change.” Journal of Policy Analysis and Management 31, no. 2: 454–61. Dahl, Gordon B., and Anne C. Gielen. 2018. “Intergenerational Spillovers in Disability Insurance.” Working Paper no. 24296. Cambridge, Mass.: National Bureau of Economic Research. Dahl, Gordon B., Andreas Ravndal Kostøl, and Magne Mogstad. 2014. “Family Welfare Cultures.” Quarterly Journal of Economics 129, no. 4: 1711–52. de Hann, Monique, and Ragnhild Camilla Schreiner. 2017. “The Intergenerational Transmission of Welfare Dependency.” Working paper. https://sites.google.com/ site/ragnhildschreiner/home/papers Finkelstein, Amy, Nathaniel Hendren, and Erzo F. P. Luttmer. 2015. “The Value of Medicaid: Interpreting Results from the Oregon Health Insurance Experiment.” Working Paper no. 21308. Cambridge, Mass.: National Bureau of Economic Research. French, Eric, and Jae Song. 2014. “The Effect of Disability Insurance Receipt on Labor Supply.” American Economic Journal: Economic Policy 6, no. 2: 291–337. Garfield, Rachel, and Anthony Damico. 2017. “The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid.” Issue Brief. Menlo Park, Calif.: Kaiser Family Foundation. Garfield, Rachel, Robbin Rudowitz, and Anthony Damico. 2018. “Understanding the Intersection of Medicaid and Work.” Issue Brief. Menlo Park, Calif.: Kaiser Family Foundation. Goldstein, Amy. 2018. “Kentucky Becomes the First State Allowed to Impose Medicaid Work Requirement.” Washington Post, January 12. Hartley, Robert Paul, Carlos Lamarche, and James P. Ziliak. 2017. “Welfare Reform and the Intergenerational Transmission of Dependence.” Discussion Paper no. 10942. Bonn: Institute of Labor Economics (IZA). Kostøl, Andreas Ravndal, and Magne Mogstad. 2014. “How Financial Incentives Induce Disability Insurance Recipients to Return to Work.” American Economic Review 104, no. 2: 624–55. Maestas, Nicole, Kathleen J. Mullen, and Alexander Strand. 2013. “Does Dis­ ability Insurance Receipt Discourage Work? Using Examiner Assignment to COMMENTS and DISCUSSION 147 Estimate Causal Effects of SSDI Receipt.” American Economic Review 103, no. 5: 1797–829. Sommers, Benjamin D. 2006. “Insuring Children or Insuring Families: Do Parental and Sibling Coverage Lead to Improved Retention of Children in Medicaid and CHIP?” Journal of Health Economics 25, no. 6: 1154–69. GENERAL DISCUSSION  Robert Moffitt complimented the authors for bringing to bear new data on expenditures on children. He had two comments. First, he noted that the paper has two distinct parts: The first documents new evidence on the effects of transfers on children, and the second explores how the distribution of transfers has changed over time. He asked what the second part implies about the first—that is, given that transfers have benefited children, what does the change in the distribution of transfers imply about which programs should be expanded? For example, should we try to redesign programs to focus on the lowest-income families instead of those with slightly higher incomes? Second, he referred to work by Janet Currie showing that cash transfers do not have the same impact as transfers targeted specifically at children.1 He wondered if it would be best to focus on programs like preschool education and the School Breakfast Program, which are more specific to children than cash transfers to families. Katharine Abraham noted that certain programs not mentioned in the authors’ literature review also have been shown to have an impact on outcomes for children. In particular, a recent paper by Fredrik Andersson and colleagues examines the long-term effects of growing up in public housing or receiving a housing voucher.2 Abraham also drew attention to the present paper’s findings on divergent trends in spending on children and the elderly, noting that, although there are strong political economy reasons to have universal assistance programs for the elderly, it would be interesting to know more about the incomes of elderly households receiving assistance. Jeffrey Campbell asked about the complementarity of parental ability and public assistance. If more effective parents are able to put public 1.  Janet Currie, “Welfare and the Well-Being of Children: The Relative Effectiveness of Cash and In-Kind Transfers,” Tax Policy and the Economy 8 (1994): 1–44; Janet M. Currie, The Invisible Safety Net: Protecting the Nation’s Poor Children and Families (Princeton University Press, 2008). 2. Fredrik Andersson, John C. Haltiwanger, Mark J. Kutzbach, Giordano E. Palloni, Henry O. Pollakowski, and Daniel H. Weinberg, “Childhood Housing and Adult Earnings: A Between-Siblings Analysis of Housing Vouchers and Public Housing,” Working Paper no. 22721 (Cambridge, Mass.: National Bureau of Economic Research, 2016). 148 Brookings Papers on Economic Activity, Spring 2018 resources to better use, then there may be some justification for moving the resources up the income distribution. N. Gregory Mankiw noted that because the number of people in each section of the income distribution is changing, changes in the shares of benefits going to different segments of the income distribution are difficult to interpret. Mankiw also mentioned that he would be interested in hearing the authors’ views on a universal basic income (UBI). Though freely admitting that a UBI was in no way politically feasible in 2018, he wondered how the kind of UBI conceptualized by Milton Friedman— or, more recently, by Chris Hughes—would compare with programs that already exist.3 Alice Rivlin mentioned that a common perception among those in the general public who oppose the social safety net is that they are “the hardworking folks who are supporting these lazy people.” The present paper, she said, offers two messages about this perception. The first one, which should be reassuring to those who oppose public assistance programs, is that assistance has shifted toward working families. The second one, however, is that as income increases, it is very difficult to know what the work incentives are. In his comment, Gordon Dahl documented the seemingly impenetrable structure of work incentives in North Carolina. Rivlin asked what the paper’s authors and other experts would do to make work incentives more sensible—suggesting, as Dahl did, that one option is to combine programs. The downside, she said, is that doing so would likely result in less money being allocated to the programs. Isabel Sawhill praised the paper as “a great synthesis of the research and wonderful data,” but she expressed concern that some of its findings on programs such as the Supplemental Nutrition Assistance Program are based on data that started being collected in the 1960s. An effect that occurred 40 or 50 years ago may not hold true today because of changes in contextual factors. For instance, malnutrition was more widespread and education was less ubiquitous in the 1960s than in 2018. Her preference is to use data on more recent cohorts of children from randomized controlled trials when available, or otherwise from quasi-experimental studies. Picking up Rivlin’s point about the shift in benefits toward working families, Sawhill remarked that she was not sure of the authors’ normative 3.  Milton Friedman advocated his notion of a “negative income tax,” which is conceptually similar to a universal basic income, in his book Capitalism and Freedom (University of Chicago Press, 1962). See also Chris Hughes, Fair Shot: Rethinking Inequality and How We Earn (New York: St. Martin’s Press, 2018). COMMENTS and DISCUSSION 149 position on this trend. She added that many of the families receiving assistance are probably female-headed, and that there had been a major change in female labor force participation over the last several decades—due in part to welfare reform, but mostly to changes in norms and opportunities for women. Finally, she was glad that the authors had focused on an “investment framework”—that is, on assistance programs as investments—but she cautioned that many of these programs may not be able to compete with other kinds of investment programs. This could be a reason to focus on motivations rooted in humanitarianism and fairness, she concluded. David Autor drew the conversation back to work incentives, saying that one distinction between programs targeted at the young and those targeted at the elderly is that for the elderly, there is no danger of substitution away from work as a result of transfers. He noted that the transfer programs discussed in the paper were also, in a sense, labor market programs. Labor market shocks feed more strongly into social safety net programs than into intended labor market programs. For example, a trade shock in a local labor market will exacerbate a larger uptake of disability insurance, Medicare, Medicaid, and other transfer programs than of unemployment insurance or trade adjustment assistance. Just as social safety nets are ultimately forced to respond to changes in labor market conditions, labor market incentives are affected by public transfers, he concluded. Kent Smetters pointed out that the median voter model could predict that transfers would increasingly go to the elderly, because the median voter will eventually become elderly but “is not going to be young someday.” And yet, he said, $1 spent on Social Security is not $1 taken away from youth. Rather, Social Security is a “pay-as-you-go game.” Michael Klein asked whether it is possible to compare trends in the distribution of transfers to children and the elderly across countries. If so, he suggested that it may be worth looking into the political reasons for differences between the United States and other countries. Richard Cooper agreed with Klein, stating that the paper “cries out for international comparison.” He mentioned Canada and Sweden as potential comparisons. He noted that the Copenhagen Consensus asked panelists to choose from a long list of international public goods that they would like to fund, assuming they had $75 billion to spend over the next five years. The first choice was reducing child malnutrition, and the second was reducing childhood diseases. These priorities seemed consistent with those laid out in the present paper. Cooper also reinforced the point made by both Dahl and Currie that the “full picture” must also pay attention to state and local spending (though Currie noted that obtaining data on state and local 150 Brookings Papers on Economic Activity, Spring 2018 programs would be a “daunting challenge”). For instance, though special education does not feature much in federal spending, Cooper noted that in Cambridge, Massachusetts, special education is roughly a quarter of the school system’s budget. Finally, Cooper objected to the authors’ lumping together of Social Security and Medicare with the other safety net programs. Social Security and Medicare are part of a “social contract,” whereby workers pay into the system during their lifetimes and receive the returns to the investment down the road. He thinks the paper fails to acknowledge the difference between public expenditures financed by dedicated taxes and those financed by general revenues. Schanzenbach first addressed the point made by some macroeconomists earlier in the writing process (and by Mankiw earlier in this discussion) that the authors should express spending in terms of shares of the population living within a certain range of the poverty level. Doing so would require relying primarily on data from the Current Population Survey (CPS), which is well known to be plagued by measurement errors. The authors went through the tedious process of obtaining administrative data primarily to avoid using the CPS, though CPS-based calculations are included in their online appendix. Additionally, not much research exists on many of the policy questions in which the authors are most interested—for example, whether $1 is better spent on the group living at between 0 and 50 percent of the poverty threshold or on those living between 100 and 150 percent, or on which program, or on people whose parents have high cognitive abilities, as Campbell had suggested. On the question of work disincentives, Schanzenbach pointed out that the paper discusses well-identified studies that have found the work disincentive effects for programs like the Supplemental Nutrition Assistance Program to be very small. Although this does not mean that doubling the safety net might not produce a larger effect, current research suggests that the programs discussed in the paper carry minimal work disincentives. On Mankiw’s question about a UBI, she noted that between the Supplemental Nutrition Assistance Program and the Earned Income Tax Credit, the current social safety net is similar to Friedman’s negative income tax. Jonathan Reeve From: Sent: To: Subject: Attachments: Moorhead, Kristina Friday, October 18, 2019 10:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] PhRMA Comment Letter TN 1115 Waiver Amendment 42 PhRMA Comment Letter TN 1115 Waiver Amendment 42.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Director Roberts,    Attached is the Pharmaceutical Research and Manufacturers of America’s letter regarding our concerns with  Amendment 42. Please feel free to contact me at 317‐341‐2207 or at this email address with any questions regarding  our comments.     Best,     Kristina M. Moorhead, MPAff  Senior Director, State Advocacy  PhRMA   Indianapolis, IN  O: 317‐295‐2964  C: 317‐341‐2207  kmoorhead@phrma.org GOBOLDLY  GoBoldly.com   Innovation.org    1 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Allison Jones Friday, October 18, 2019 2:09 PM PUBLICE NOTICE TENNCARE Russell Overby; Shelby Dodson [EXTERNAL] Legal Aid Society Comments to Proposed Amendment 42 Legal Aid Society Comments to Proposed Amendment 42 10.18.19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good afternoon.    Please find attached comments submitted by the Legal Aid Society of Middle Tennessee on behalf of our clients and the  communities we serve.    Thank you for the opportunity to comment on the proposed rule changes.    Sincerely,  Allison Jones  ALLISON JONES   1321 Murfreesboro Pike  Suite 400  Nashville,  TN   37217 Attorney ajones@las.org Direct:  (615) 780‐7105 Toll Free:  (800) 238‐1443 Fax:  (615) 244‐4920   www.las.org              Confidentiality Notice: The foregoing message and all attachments transmitted with it may contain  legally privileged and confidential information intended solely for the use of the individual or entity to whom it is addressed. Privileges are not waived by virtue of this having been sent by electronic transmission. If the reader of this message is not the intended recipient, you are hereby notified that  forwarding,  communicating,  disseminating,  distributing,  copying,  or  otherwise  using  this message or its attachments is strictly prohibited. If you believe you have received this transmission  in error, please notify the sender immediately and delete the information without retaining any copies. Thank you.        1 Jonathan Reeve From: Sent: To: Subject: Attachments: LCAO Friday, October 18, 2019 2:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] LCAO Letter responding to TN's draft Section 1115 demonstration waiver amendment (Amendment 42) LCAO Letter Opposing TN Block Grant Proposal FINAL.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts, The Leadership Council of Aging Organizations (LCAO) appreciates this opportunity to respond to Tennessee’s draft Section 1115 demonstration waiver amendment (Amendment 42). Sincerely, the undersigned organizations of the LCAO coalition. AARP - 601 E. Street, NW Brickfield Center Washington, DC 20049     1 Debra B. Whitman, Chair October 18, 2019 Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Submitted by e-mail: public.notice.tenncare@tn.gov Dear Director Roberts, The Leadership Council of Aging Organizations (LCAO) appreciates this opportunity to respond to Tennessee’s draft Section 1115 demonstration waiver amendment (Amendment 42)1 which seeks to establish block grant funding for its mandatory Medicaid populations. We strongly oppose this proposal. LCAO is a coalition of national nonprofit organizations concerned with the well-being of America’s older population and committed to representing their interests in the policy-making arena. The coalition serves as a source of information about issues affecting older adults and provides leadership and vision as the United States works to meet the challenges and opportunities presented by our aging society. LCAO organizations have expertise in health care, economic security, nutrition and food security, housing, elder justice, and other issues facing people with disabilities and older adults. Although our coalition typically focuses on national policy, many of our member organizations also advocate on behalf of older Americans living in Tennessee. Moreover, when a state-based policy could set a very negative precedent for older adults and their families in other parts of the country—as Amendment 42 would—LCAO is compelled to address it. The stated goal of Amendment 42 is to “convert the federal share of [Tennessee’s] Medicaid funding relating to providing its core medical services to its core population”2 to a block grant, thereby capping Medicaid expenditures for core populations. LCAO strongly opposes such a restructuring, as it would undermine the main objective of the Medicaid program: to help states provide medical assistance to residents whose incomes and resources are insufficient to meet the costs of necessary medical services. A block grant would create inflexible limitations on the Division of TennCare, “TennCare II Demonstration: Project No. 11-W-00151/4, Amendment 42 DRAFT” (September 2019), https://www.tn.gov/content/dam/tn/tenncare/documents2/TennCareAmendment42.pdf. 2 Id. 1 601 E Street, NW  Washington, DC 20049 (202) 434-3055 – Direct Line  (202) 434-3720 – Reception Line  (202) 434-6613 - Fax Email: LCAO@aarp.org  Website: www.LCAO.org availability of federal funding, regardless of providers’ changes to service costs or residents’ need for service utilization. Moreover, Amendment 42 would create incentives for Tennessee to reduce enrollment and its own investment in the program and would eliminate federal oversight. This means Medicaid’s most critical access and health care protections would be stripped away at a time when the older adult population is growing rapidly and economic insecurity, especially among people with disabilities and older adults, is increasing.3 LCAO also has serious concerns about how the waiver is designed and how the provisions are described. Amendment 42 lacks clarity on the state’s intended impact on older adults. For example, it is unclear whether TennCare plans to exclude from the block grant expenses for all dually eligible beneficiaries, regardless of age or type of Medicaid coverage. The state should clarify this point and update its base calculations, if needed. Implementation of Amendment 42 would inhibit TennCare’s ability to serve people with disabilities and older adults, exacerbating residents’ economic insecurity and worsening their health outcomes. We strongly urge you to withdraw the proposal in its entirety and focus on improving and expanding coverage to low-income Tennesseans, including older adults and people with disabilities. Thank you for your consideration of our comments. Sincerely, AFL-CIO Aging Life Care Association Alliance for Aging Research Alliance for Retired Americans American Association of Service Coordinators (AASC) American Society on Aging Association for Gerontology and Human Development in HBCUs B'nai B'rith International Center for Medicare Advocacy Community Catalyst Families USA The Gerontological Society of America International Association for Indigenous Aging The Jewish Federations of North America Justice in Aging Meals on Wheels America Medicare Rights Center Military Officers Association of America National Academy of Elder Law Attorneys National Adult Protective Services Association National Association for Hispanic Elderly See, e.g., Tatjana Meschede, et al., “From Bad to Worse: Senior Economic Insecurity on the Rise,” INSTITUTE ON ASSETS AND SOCIAL POLICY (July 2011), https://www.demos.org/sites/default/files/publications/FromBadToWorse_Senior_Economic_Insecurity.pdf. 3 2 P a g e National Association for Home Care and Hospice National Association of Area Agencies on Aging (n4a) National Association of Nutrition and Aging Services Programs National Association of Social Workers National Association of State Long-Term Care Ombudsman Programs National Committee to Preserve Social Security And Medicare National Consumer Voice for Quality Long-Term Care National Council on Aging National Indian Council on Aging, Inc. PHI Service Employees International Union Social Security Works 3 P a g e Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Leanne Durm-Minoux Tuesday, October 15, 2019 9:59 AM PUBLICE NOTICE TENNCARE Katie Berge; Jordan Endicott; Nathan Mick; Kristin Palmer [EXTERNAL] AHA Comments - TennCare 1115 Waiver - Block Grant Letter 10.15.19 TennCare 1115 Waiver Block Grant Letter. 10.14.19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please find comments from the American Heart Association attached.    Thank You,  Leanne Durm‐Minoux      Leanne Durm‐Minoux    Tennessee Government Relations Director  American Heart Association  1818 Patterson St.   Nashville   TN   37203  O 615‐340‐4155   M 615‐815‐9103  leanne.durm‐minoux@heart.org      1 October 14, 2019 Mr. Gabe Roberts Deputy Commissioner & Director of TennCare Division of TennCare Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: The American Heart Association (AHA) appreciates the opportunity to submit comments on the Tennessee Division of TennCare’s 1115 waiver application. As the nation’s oldest and largest organization dedicated to fighting heart disease and stroke, we would like to express our serious concerns with the waiver. The AHA represents over 100 million patients with cardiovascular disease (CVD) including many who rely on Medicaid as their primary source of care.1 In fact, twenty-eight percent of adults with Medicaid coverage have a history of cardiovascular disease.2 Medicaid provides critical access to prevention, treatment, disease management, and care coordination services for these individuals. Low-income populations are disproportionately affected by CVD with adults reporting higher rates of heart disease, hypertension, and stroke. For millions of Americans with CVD, Medicaid is the coverage backbone for the healthcare services individuals need to maintain or improve their health. The connection between health coverage and health outcomes is clear and well documented. Americans with CVD risk factors who lack health insurance or are underinsured have higher mortality rates3 and poorer blood pressure control4 than their insured counterparts. Furthermore, uninsured stroke patients 1 RTI. Projections of Cardiovascular Disease Prevalence and Costs: 2015–2035, Technical Report. http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_491513.pdf Accessed June 19, 2017. 2 Kaiser Family Foundation. The Role of Medicaid For People with Cardiovascular Diseases. 2012. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8383_cd.pdf. Accessed August 15, 2016. 3 McWilliams JM, Zaslavsky AM, Meara E, Ayanian JZ. Health insurance coverage and mortality among the near-elderly. Health Affairs 2004; 23(4): 223-233. 4 Duru OK, Vargas RB, Kerman D, Pan D, Norris KC. Health Insurance status and hypertension monitoring and control in the United States. Am J Hypertens 2007; 20:348-353. suffer from greater neurological impairments, longer hospital stays,5 and a higher risk of death6 than similar patients covered by health insurance. Tennessee is already ranked 42nd in the nation in health outcomes, and 45th in cardiovascular deaths.7 Imposing a block grant on the state’s Medicaid program could harm Tennesseans who are already facing troubling health outcomes. The purpose of the Medicaid program is to provide affordable healthcare coverage for low-income individuals and families, including those in Tennessee. Since its creation in 1965, Medicaid has functioned as an entitlement program, meaning that any person who meets the income threshold and other criteria set by the federal government and states is guaranteed coverage. The proposed conversion from a traditional match-based funding structure to a block grant, combined with the state’s broad request to be exempted from certain oversight and quality requirements, could jeopardize patients’ ability to access necessary care – undermining the core intent of the Medicaid program. For this reason, the AHA strongly opposes this waiver. Block Grant Financing Model The AHA strongly opposes Tennessee’s proposal to change the financing structure away from the traditional state-federal match, to a block grant. As the gap between the block grant and actual costs of care increases over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients will only increase. While the state repeatedly emphasizes this change in funding will have no impact on the Medicaid population, the structure and authorities requested in the waiver provide few reassurances patients will be guaranteed access to sustaining and life-saving care should the state experience fiscal stress. This structure poses significant financial risk to both the state and Medicaid beneficiaries. The per capita adjustments to the block grant will not be sufficient if an unexpected event, such as a public health crisis, increases per-person, healthcare costs. For example, there are many ground-breaking treatments in development for patients with serious and chronic illnesses. If an expensive but highly effective treatment became available, Tennessee’s spending could rise, putting the state’s budget at risk and creating an incentive for the state to impose additional barriers for that treatment. It is also concerning the state is requesting the U.S. Department of Health and Human Services (HHS) approve a block grant given that statute does not permit this through a section 1115 waiver. The Secretary of Health and Human Services is not permitted to waive Sections 1903 and 1905 of the Social Security Act, where the financing structure of the Medicaid program is located, through these types of waivers.8 Such fundamental changes to the core functions of the Medicaid program would require Congressional action and authority which are notably absent. We are further concerned that should this waiver be approved; the waiver will be challenged in the courts at significant cost to the state and federal government – dollars that could be better spent on delivering care to Tennessee’s Medicaideligible population. 5 Rice T,LaVarreda SA,Ponce NA, Brown ER. The impact of private and public health insurance on medication use for adults with chronic diseases. Med Care Res Rev 2005; 62(1): 231-249. 6 McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007; 298:2886 –2894. 7 America’s Health Rankings 2018 Annual Report, United Health Foundation. https://assets.americashealthrankings.org/app/uploads/ahrannual-2018.pdf. Accessed October 9, 2019. 8 Joan Alker. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown University Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/ pending-cms-guidance-on-medicaid-block-grants-executive-overreach-strikes-again/. Prescription Drug Access As a key driver of healthcare costs, we understand the need to manage prescription drug costs. However, the American Heart Association is deeply concerned about the state’s proposal to create a closed formulary with as few as one drug per class and exclusion of prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated approval process. These changes, if approved, would impose unnecessary barriers to needed medications for CVD patients. Prescription drugs are a lifeline for people living with chronic and complex conditions, especially those with cardiovascular disease, and further restrictions on access to medications will only serve as an additional barrier to obtaining the treatment regimens most appropriate for these individuals. People with complex medical conditions are often treated for multiple ailments, requiring careful and complex management to arrive at patient-specific treatment plans. A closed formulary would restrict the drugs TennCare covers, with as few as one drug available per therapeutic class. It is important physicians are able to provide treatment based on patients’ needs, not on availability of coverage in TennCare, driven solely by cost savings concerns. If despite these strong objections, Centers for Medicare and Medicaid Services (CMS) approves the request for a limited formulary, any such approval should be conditioned on the state adopting more consumer protections than it has proposed, such as adopting the patient protections afforded Medicare Part D patients in their selection of a pharmacy plan with a closed formulary. At the very least, the formulary should adhere to the guidelines set forth in the Medicare Prescription Drug Benefit Manual – Chapter 6 Part D Drugs and Formulary Requirements. Section 30.2 requires two drugs per category or class be made available in a given formulary – not the possible single drug as currently proposed. We further recommend that the rule set forth in the Medicare Prescription Drug Manual at Section 30.2.5 “Protected Classes” be adopted. This rule states “Part D sponsor formularies must include all or substantially all drugs in the immunosuppressant (for prophylaxis of organ transplant rejection) antidepressant, antipsychotic, anticonvulsant, antiretroviral, and antineoplastic classes.” Furthermore, there should at a minimum, be a robust exceptions process to cover drugs not on the formulary, including but not limited to exceptions to address adverse drug reactions, drug interactions or specific clinical needs of a patient. Exceptions should also take into consideration the ability of enrollees to adhere to a treatment regimen. TennCare must ensure the exceptions process is accessible, easy to navigate, and timely. State Flexibilities The AHA also opposes several, proposed components in the waiver application under the broad moniker of “state flexibilities.” Tennessee is asking to be exempt from federal standards and requirements for its managed care program, including the Managed Care Rule. This important safeguard ensures Medicaid Managed Care Organizations (MCOs) must meet certain requirements related to patient care. For example, the managed care rule sets standards related to adequate networks, so patients can actually see the appropriate providers and receive the care they need. The managed care rule requires MCOs to comply with standards of time and distance to measure this network adequately, helping patients access both primary care providers and specialists they need. Tennessee is also asking to change the “amount, duration, and scope” of benefits, which could allow the state to put caps on services or only cover critical services for certain individuals. The Medicaid population, by definition, is a vulnerable population. Allowing Tennessee to change the “amount, duration, and scope” of benefits could negatively impact care and outcomes for some of the state’s most vulnerable populations. Finally, the state would no longer need to get approval to make changes to benefits and services in the future and would like to make this demonstration permanent, removing important opportunities for the public to provide feedback on the how the program is working for key stakeholders, before any policy changes are implemented. It is especially important beneficiaries impacted by the demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint venture between Tennessee and CMS. Both entities, as well as the people they serve, should have a voice in how the program is administered. Fiscal Sustainability Tennessee also has yet to provide a complete budget neutrality estimate with details of the projected changes in spending with the waiver and any impact on coverage. The federal rules at 431.408 pertaining to state public comment process require at (a)(1)(i)(C) that a state include an estimate of the expected increase or decrease in annual enrollment and expenditures if applicable. The intent of this section of the regulations is to allow the public to comment on a Section 1115 proposal with adequate information to assess its impact. Given that this waiver represents a fundamental change to Tennessee’s demonstration, the state should include these projections and an impact assessment on budget neutrality provisions. Conclusion Creating such sweeping changes to the core functions of Medicaid in Tennessee could seriously jeopardize the health and welfare of vulnerable patients. In addition to the AHA’s noted concerns regarding the quality of care that would be provided under this waiver, there are also issues with requesting a waiver HHS does not have the authority to grant, and TennCare’s failure to provide a complete, budgetary analyses in accordance with federal guidelines. Affordable, quality healthcare access is critically important for Tennesseans, and the core objective of the Medicaid program is to furnish healthcare to low-income populations. This waiver does not further this goal. Should you have any questions, please do not hesitate to contact me at leanne.durm-minoux@heart.org or 615-340-4155. We appreciate the opportunity to offer comments on this waiver request. Sincerely, Leanne Durm-Minoux Tennessee Government Relations Director Jonathan Reeve From: Sent: To: Subject: Attachments: Baroni-Allmon, Tracy Thursday, October 17, 2019 10:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Novartis comments on the State's waiver proposal Novartis Comments TN Medicaid Block Grant Waiver Oct 17 2019.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good morning. Attached are comments submitted on behalf of Novartis Pharmaceuticals Corporation. We appreciate the opportunity to comment, and look forward to continued discussions with the State to ensure that changes made are in the best interests of patients. Best regards,  Tracy      Tracy Baroni Allmon, BS Pharm., J.D.  Executive Director, State Health Policy  Novartis Services  801 Pennsylvania Avenue, Suite 700  Washington, DC 20004  Mobile: (410) 443‐8689    1 Novartis Services, Inc. One Health Plaza East Hanover, NJ 07936 Leigh Anne Leas North America Head, Public Policy Telephone +862-778-3284 October 17, 2019 Electronic Submission Mr. Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: Comments on Notice of Change in TennCare II Demonstration: Amendment 42 Dear Director Roberts: Novartis appreciates the opportunity to comment on Tennessee’s Section 1115 Demonstration: Amendment 42 (“proposed waiver”), which is intended for submission to the Centers for Medicare & Medicaid Services (CMS) by November 25, 2019. In these comments, we share our significant concerns with the proposed waiver. Novartis provides healthcare solutions that address the evolving needs of patients and societies worldwide. Our broad portfolio includes innovative pharmaceuticals, oncology medicines, high quality generic and biosimilar medicines. At Novartis, we are united by a single purpose: reimagining medicine to improve and extend people’s lives. Through science-based innovation, we address some of society’s most challenging healthcare issues. Every day we work to discover and develop breakthrough treatments and find new ways to deliver them to as many people as possible. The proposed waiver presents several fundamental legal and policy-based concerns and threatens to harm Medicaid beneficiaries. We firmly believe that Tennessee should revise its approach and not proceed with the proposed waiver as written on several grounds: x x x x The proposed waiver undermines both the bargain that Congress struck in enacting the Medicaid Drug Rebate Program, and contradicts the basic terms of the Medicaid rebate agreement, which have contributed to the drug rebate program successes over the past three decades; The proposed waiver excludes safeguards that Congress has affirmed as essential in the provision of services within state Medicaid programs; The proposed waiver requests permission for Tennessee to limit drug coverage in an inappropriate manner that would fundamentally harm Medicaid beneficiaries; The proposed waiver fails to satisfy the statutory requirements for a Section 1115 demonstration program; Page 2 of 10 x x The proposed waiver should instead pursue implementation of alternative payment methodologies; and The proposed waiver stands to adversely impact quality, as demonstrated by quality measures. The Proposed Waiver Violates the Bargain Underlying the Medicaid Drug Rebate Program and Enshrined in the Medicaid Drug Rebate Agreement. First, the proposed waiver violates the bargain struck by Congress in enacting the Medicaid Drug Rebate Program, Social Security Act (SSA) § 1927. SSA § 1927 codifies a carefully-crafted compromise between manufacturers and states: a manufacturer that is party to a Medicaid drug rebate agreement (MDRA) provides generous rebates to state Medicaid programs in exchange for the coverage by the state of all of the manufacturer’s Food and Drug Administration- (FDA-) approved covered outpatient drugs. Although SSA § 1927 has been amended over the years since the statute’s 1990 enactment, including through changes that require substantially larger rebates from manufacturers, the fundamental bargain has endured. The bargain is further memorialized in the rebate agreement that manufacturers enter into with the Secretary of Health and Human Services, under which manufacturers agree that, in exchange for federal approval of the payment by state Medicaid programs for their drugs, they will make rebate payments on all of their covered outpatient drugs “for as long as an agreement with the Secretary is in force and state utilization data reports that payment was made for that drug.” 1 As a result of this agreement between states and manufacturers, over the past several decades SSA § 1927 has helped provide Medicaid beneficiaries with access to critical, innovative, life-saving therapies and has helped ensure that states receive substantial rebates on the cost of those therapies. The proposed waiver would introduce an unprecedented and inappropriate departure from this long-standing arrangement. In simple terms, Tennessee is proposing to waive only its obligations under the rebate agreement – namely, Tennessee proposed to be relieved of its obligation to cover all covered outpatient drugs of a manufacturer that has entered into a rebate agreement with the Secretary of Health and Human Services. However, it appears that the State would still expect manufacturers to pay rebates in connection with the state Medicaid program’s utilization of its drugs. This proposal is fundamentally inconsistent with the Congressional intent underlying SSA § 1927 and with the rebate agreement memorializing the terms of § 1927 bargain. Under SSA § 1927, manufacturers are incentivized to offer generous rebates in exchange for the promise of state Medicaid program coverage of all rebated covered outpatient drugs. To strip away only the states’ obligations under this bargain would be unfair and would subvert Congressional intent. The State of Tennessee should be required to uphold its commitment to the grand bargain by eliminating this provision from the proposed waiver. 1 See Rebate Agreement between the Secretary of Health and Human Services and the Manufacturer, § II (j), 83 Fed. Reg. 12770, 12785 (Mar. 23, 2018). Page 3 of 10 The Proposed Waiver Fails to Include Congressionally-Designed and Mandated Safeguards. Second, the proposed waiver fails to include essential safeguards that Congress incorporated into SSA § 1927 and has since affirmed. In the plain text of SSA § 1927, Congress narrowly (and exhaustively) outlines the ways in which states may limit access to covered outpatient drugs. For example, Congress has created an avenue through which states can limit their coverage of covered outpatient drugs by creating a formulary. However, Congress requires that the formulary have various safeguards for Medicaid beneficiaries, including: i) a drug may only be excluded from a formulary on the basis of a clinical determination based on the drug's label, ii) the state must provide a written explanation of its decision to exclude a drug in such a manner, and iii) the state must still make such a drug available through a federally-compliant prior authorization process. 2 Specifically, federal law establishes that a formulary must meet the following requirements: (A) The formulary [must be] developed by a committee consisting of physicians, pharmacists, and other appropriate individuals appointed by the Governor of the State (B) Except as provided in subparagraph (C), the formulary [must] include [ ] the covered outpatient drugs of any manufacturer which has entered into and complies with an agreement under subsection (a)... (C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease or condition for an identified population (if any) only if, based on the drug's labeling…the excluded drug does not have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome of such treatment for such population over other drugs included in the formulary and there is a written explanation (available to the public) of the basis for the exclusion. (D) The State plan permits coverage of a drug excluded from the formulary...pursuant to a prior authorization program. 3 (E) States may not limit coverage of drugs in a formulary in a manner that ignores these safeguards. 4 Indeed, CMS has emphasized that states may not restrict access to therapies by imposing conditions for coverage that may unreasonably restrict access to these drugs or otherwise limit access in manners that are contrary to the statutory requirements of § 1927. 5 (F) The proposed waiver would disregard the safeguards that Congress instituted under § 1927. Tennessee has proposed to introduce a “closed formulary” that is not, in fact, a formulary as that term is recognized under SSA § 1927(d)(4). The “closed formulary” would restrict coverage in 2 See SSA § 1927(d)(4). See id. 4 See, e.g., 60 Fed. Reg. 48442, 48454 (Sept. 19, 1995) (noting that “it is necessary to prevent states from using a prior authorization program as a proxy for a closed formulary” other than as provided in SSA § 1927(d)(4)). 5 See CMS, Medicaid Drug Rebate Program Notice, Release No. 172, Assuring Medicaid Beneficiaries Access to Hepatitis C (HCV) Drugs (Nov. 5, 2015). 3 Page 4 of 10 manners that are not permissible under federal law. For example, it would neither limit clinical determinations regarding a drug’s therapeutic advantage to determinations based on a review of the drug's label, nor make available to the public a written explanation of the state’s decision to exclude a particular drug from the formulary. Instead, Tennessee would include as few as one drug per therapeutic class, irrespective of whether additional drugs qualify as “covered outpatient drugs” under § 1927 or would be medically appropriate – and superior, from a patient health standpoint – to the single available drug. Tennessee further proposes to “exclude… new drugs [that] have not yet demonstrated actual clinical benefit and have been studied in clinical trials using only surrogate endpoints…from its formulary until market prices are consistent with prudent fiscal administration or the state determines that sufficient data exist regarding the cost effectiveness of the drug.” Novartis has significant concerns that Tennessee has: (i) proposed flawed criteria for concluding that there is no “demonstrated actual clinical benefit,” and (ii) will use such broadly- and vaguely-worded criteria to limit access to life-saving therapies that Congress intended to cover. FDA has allowed for approval of a particular therapy based on a reported surrogate endpoint, rather than a clinical outcome, where it would be too challenging or inappropriate to measure a defined clinical outcome for that therapy. As an example, the surrogate endpoint of bone mineral density might be utilized, rather than the clinical outcome of hip fractures, because requiring the clinical outcome would require an unreasonably large and lengthy clinical trial given the relatively low incidence of hip fracture. In instances where the FDA has approved a drug based on trials utilizing surrogate endpoints, Tennessee should not exclude coverage of these therapies merely because only surrogate endpoints have been reported. Tennessee proposes to exclude from coverage various therapies that have been approved by the FDA through the accelerated approval pathway. Tennessee would thereby substitute its judgment regarding whether products meet certain clinical efficacy criteria over the judgments of the key federal regulatory agency tasked with making such determinations — the FDA. Indeed, a decision by the FDA to approve a drug based on surrogate endpoints, or contingent on confirmatory trials, does not reflect a judgment by the agency that the drug has no “demonstrated actual clinical benefit; it is improper for Tennessee to make such a judgment when the federal agency with the legal and regulatory authority and clinical expertise to make such determinations has not done so. As concerning is the attempt by the State to subvert the FDA’s policy priority of accelerating patient access to innovative therapies. In this age of pharmaceutical innovation, the FDA has created an accelerated approval pathway in order to expedite the process for the agency's approval of safe and effective drugs for patients with serious and/or unmet medical needs. We submit that Tennessee’s proposed waiver will likely result in harm to patients with serious and unmet medical needs by undermining this important policy objective. Page 5 of 10 CMS has affirmed that such therapies qualify as covered outpatient drugs that are subject to coverage. Indeed, on June 27, 2018, CMS sent a notice to states regarding Medicaid coverage for FDA approved drugs under the accelerated approval pathway stating: this release clarifies that drugs that are granted “accelerated approval” are drugs approved by FDA under section 505(c) of the [Federal Food, Drug, and Cosmetic Act], and are able to satisfy the definition of covered outpatient drug, and if used for a medically-accepted indication, then the drug must be covered by state Medicaid programs if the manufacturer has an applicable signed Medicaid national drug rebate agreement for participation in the MDRP. States can use utilization management mechanisms such as prior authorization to assure appropriate use of these medications. 6 The agency has, therefore, clarified that, consistent with § 1927, states may assure appropriate use of such therapies by utilizing prior authorization processes. However, wholesale denying access to such potentially-life-saving therapies would be detrimental to the health and well-being of Medicaid beneficiaries. The Proposed Waiver Would Potentially Harm Medicaid Beneficiaries. On the whole, the proposed waiver threatens to deprive patients of appropriate therapies to which they would likely have access in the absence of a waiver, and to thereby result in those patients receiving therapies that may not be clinically optimal or even appropriate. There are instances when a particular drug in a therapeutic class is inappropriate for a particular patient, whereas another drug – potentially not covered by Medicaid under the proposed waiver – would better meet the patient's medical needs. For example, providers may try multiple anti-psychotic therapies before finding an appropriate one for a particular patient. Also, patients who have an adverse reaction to one therapy in a category (e.g., insulin) may not have an adverse reaction to another therapy. Tennessee’s proposal to limit coverage to one drug per class would undermine the patient’s access to the particular therapy that is best-suited for his or her needs. The proposed waiver risks depriving Medicaid beneficiaries in Tennessee of therapeutic advances, including personalized medicines based on their unique medical needs and biological make-up that would be available to non-Medicaid 6 See CMS letter to states Medicaid Drug Rebate Notice Release 185 https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescriptiondrugs/downloads/rx-releases/state-releases/state-rel-185.pdf Page 6 of 10 beneficiaries in Tennessee and Medicaid beneficiaries in other states. Indeed, the proposed “closed formulary” threatens to prevent the state’s most vulnerable residents from accessing such innovative therapies, without regard to the appropriateness of the therapy and the possibility of better health outcomes and fewer side effects. Medicaid beneficiaries, unlike persons with greater financial means, are not afforded an opportunity to select an alternative coverage policy when a drug is not available through the Medicaid program. As such, the proposed waiver threatens to create a profoundly inequitable brand of second-class health care in Tennessee. We note that should Tennessee wish to limit coverage of covered outpatient drugs, it can do so by establishing a “formulary” that comports with § 1927(d)(4)’s requirements. Under the proposed waiver, it does not appear that Tennessee will attempt to design appropriate coverage policies consistent with this federallypermitted option. Tennessee should avail itself of the opportunities that already exist under federal law rather than deprive Medicaid beneficiaries of access to innovative therapies in contravention of § 1927. We urge Tennessee to consider beneficiary access as a guiding principle for designing any waiver or model, especially with regard to the Medicaid population. Limitations on access to drugs could adversely affect beneficiary health and lead to increased overall costs for the Medicaid program, and thus for taxpayers. Every waiver or other model that is approved for Medicaid should be designed in a way that protects beneficiary access to prescription drugs, incentivizes better health outcomes, and aligns payment with value. Additionally, we encourage Tennessee to follow a collaborative approach in working with relevant stakeholders and focus on initiatives that drive value-based care while not restricting access to medicines. The Proposed Waiver Fails to Satisfy the Federal Criteria for a Section 1115 Waiver. The proposed demonstration program fails to satisfy foundational requirements of demonstration projects under SSA § 1115. Under federal law, a demonstration program must be “likely to assist in promoting the objectives of [the Medicaid program]”5 — i.e., it must assist in providing support to low-income individuals who, in the absence of the Medicaid program, may lack coverage for health services. The State’s proposed “closed formulary” manifestly fails to satisfy this requirement. It would not assist Medicaid beneficiaries in accessing health services. Rather, it would unquestionably lead to narrower drug coverage and, for many patients, could deprive them of appropriate therapies to which patients would have had access in the absence of the proposed waiver. As CMS has previously acknowledged, drug coverage restrictions “could result in recipients being treated with alternate therapies that may not be in their best interest. This could result in increased program costs if other medical services, such as inpatient hospital services, are necessary because a drug Page 7 of 10 therapy is made less accessible under the State Medicaid program.” 7 The proposed waiver would also impose increased administrative costs on patients, providers, and Tennessee. This is because the proposed “closed formulary,” with as few as one drug per therapeutic class, would necessarily result in patients seeking exceptions on a frequent basis, as many off-formulary therapies would be prescribed as medically necessary. The proposed waiver also fails to set forth a true “experimental, pilot, or demonstration project” — another federal requirement for Section 1115 waivers. At least one court has affirmed that, in reviewing a proposed demonstration project, the “Secretary must make some judgment that the project has a research or a demonstration value. A simple benefits cut, which might save money but has no research or experimental goal, would not satisfy this requirement.” 8 The proposed demonstration would institute such a “simple benefits cut,” without serving a research or experimental goal. Accordingly, it lacks an essential requirement of SSA § 1115, and neither Tennessee should propose it, nor should CMS approve it. CMS Rejected the Massachusetts 1115 Waiver Demonstration that Sought to Limit Medication Access On June 27, 2018, CMS sent a letter to Massachusetts, denying its request to create a closed formulary for the MassHealth (Medicaid) population. CMS stated that while it is supportive of Massachusetts’ effort to lower drug costs, its plan must be altered. The agency said that it would consider a similar demonstration project if Massachusetts (or another state) instead directly negotiated with pharmaceutical manufacturers and agreed to forgo rebates under the federal Medicaid Drug Rebate Program (MDRP). “The state could then be provided flexibility to exclude specific drugs from coverage based on cost effectiveness or other approved criteria, or to employ a closed formulary structure similar to Medicare Part D or commercial plan formularies,” CMS wrote. “Under such an approach, the state would have to ensure that federal expenditures under the demonstration would not exceed federal expenditures incurred without the demonstration.” 9 The Proposed Waiver Should Consider Alternative Payment Models. We appreciate that the State has significant concerns regarding prescription drug spending. In Tennessee, however, Medicaid prescription drug spending comprises less than .5% of the total state budget, and only 4% of the Medicaid budget is spent on 60 Fed. Reg. at 48454. Beno v. Shalala, 30 F.3d 1057, 1069 (9th Cir. 1994). 9 See CMS, 11-W-00030/1 https://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf. 7 8 Page 8 of 10 retail medications, inclusive of all rebates. As an alternative to draconian access restrictions, a number of states are experimenting with new methods of Medicaid prescription drug contracting through alternative payment models (APMs) for higher cost medications and/or for medications that meet an urgent public health need. APMs aim to promote value via savings on the total cost of care, total savings for a specific population, improved access, and/or better outcomes. States that pursue market-based alternatives such as these can improve access to therapies, lower overall spend, and/or improve health outcomes while incentivizing manufacturers to compete on attributes that include access, cost, quality, and value. Oklahoma, Colorado and Michigan have all been approved by CMS for Medicaid supplemental rebate agreements (SRAs) that allow for outcomes-based contracting with pharmaceutical manufacturers for a variety of treatments. Louisiana and Washington have received CMS approval of SRA arrangements that allow for Hepatitis C “subscription agreements,” and at least 14 states use risk distribution models including high-risk pools, reinsurance and risk corridors to help manage program costs. These states have developed approaches that address spending concerns while also maintaining, and even improving, Medicaid beneficiary access to innovative medicines. Tennessee should pursue these types of program reforms rather than changes that threaten Medicaid beneficiary access to potentially life-saving therapies. The Proposed Waiver Does Not Consider the Impact on Quality of Care and How That Would Be Reflected in Key Quality Measures: Tennessee requires that its health plans maintain accreditation by The National Committee for Quality Assurance (NCQA) – an independent organization that assesses and scores health plan performance in various areas, including quality improvement, utilization management, provider credentialing, and member rights and responsibilities. NCQA relies on regular reporting of Healthcare Effectiveness Data and Information Set (HEDIS) 10 data. As such, Tennessee has assembled historical data results on HEDIS measures and has boasted improvements on 81% of the HEDIS quality measures tracked since 2007. 11 A number of these HEDIS measures relate to the appropriate use of medicines in order to achieve high quality of care. For example, “Controlling High Blood Pressure” evaluates the percentage of adult patients diagnosed with hypertension whose blood pressure is controlled at 140/90 mmHg. While for some patients it may be possible to achieve normal blood pressure by eating a healthier diet and exercising regularly, many patients will require use of antihypertensives to achieve controlled blood pressure, and still some patients will require a combination of medications. Implementation of a narrow formulary likely would result in many patients with hypertension no longer having control of their blood pressure simply because they can no longer access treatments that work for them. Therefore, not only will hypertensive patient outcomes stand to suffer under the proposed restrictive formulary, but health plan HEDIS performance may also deteriorate because of the new policy, potentially jeopardizing their accreditation. 10 11 https://www.ncqa.org/hedis/measures/ https://www.tn.gov/content/dam/tn/tenncare/documents/TennCareOnePager.pdf Page 9 of 10 The HEDIS measure set includes several measures that evaluate care for chronic conditions, such as hypertension, asthma, chronic obstructive pulmonary disease, and diabetes. The policies in the proposed waiver stand to adversely impact the results of each of these measures because ensuring appropriate use of medicines and long-term disease control may not be possible with a narrow formulary. These quality measure results could very well foretell the harmful ramifications of the proposed waiver’s formulary restrictions. Quality measures, such as the HEDIS set, can be utilized as a good tool to reveal areas of care that require attention and improvements, as well as a tool to motivate health plans and other players in the healthcare system to improve the quality of care that they are rendering if the correct incentives are in place. However, in order to provide high quality care and to attain to any attached incentives, health plans, clinicians, and hospitals must have the necessary treatment options available to appropriately treat their patients. Moreover, and relatedly, patients’ quality of care and health outcomes likely would be negatively impacted by such a narrow formulary. Additional negative health impacts and consequences could result from poorly controlled hypertension, diabetes, and respiratory conditions, such as acute myocardial infarctions, kidney disease, and neuropathies, causing increased expense to the State. Novartis urges Tennessee to evaluate the consequences of the proposed waiver’s policy for formulary construction and to ensure that patients are able to access the full range of medicines needed to address their common chronic conditions. Prohibiting access to needed medicines likely will result in uncontrolled conditions and related avoidable expenses in the long term. Conclusion In sum, the proposed waiver poses a great risk to the health and well-being of Medicaid beneficiaries in Tennessee. It would also mark a serious departure from the principles undergirding SSA § 1927, and from CMS’ long-standing policy of “remain[ing] committed to Medicaid beneficiaries continuing to have access to needed prescribed medications.” 12 It also fails to satisfy the essential criteria for a § 1115 demonstration program. As such, Novartis strongly objects to the proposed waiver and encourages Tennessee to revise its proposal. Moving forward, Novartis would like to work with Tennessee to develop meaningful solutions to meet its budgetary goals while upholding the current Medicaid rebate statute. We stand ready to work with the State if there is interest in applying for a state plan amendment to implement APMs and/or instituting quality measures as a See CMS, Medicaid Drug Rebate Program Notice, Release No. 172, Assuring Medicaid Beneficiaries Access to Hepatitis C (HCV) Drugs (Nov. 5, 2015). 12 Page 10 of 10 way to ensure that TennCare beneficiaries have access to life-saving and lifeenhancing medications. ***** We appreciate the opportunity to comment and would be happy to provide further information regarding our comments above. Please feel free to contact me at 862778-3284 if we can provide further assistance. Sincerely, Leas Leigh Anne Digitally signed by Leas Leigh Anne DN: dc=com, dc=novartis, ou=people, ou=GR, serialNumber=880928, cn=Leas Leigh Anne Date: 2019.10.15 17:06:44 -04'00' Leigh Anne Leas Vice President and North America Head, Public Policy Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Abby Trotter Friday, October 18, 2019 10:33 AM PUBLICE NOTICE TENNCARE Jack Geisser; Angela Gochenaur; Ted Townsend; Megan Lane [EXTERNAL] Life Science TN and BIO public comment LST TennCare Waiver Public Comment Letter 10.18.19.pdf; Tennessee Waiver Amend 10_18_ 19v.FINAL.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good morning. Please see attached two public comment letters regarding the TennCare Waiver draft. Thank you for the  opportunity to submit our thoughts.      Best regards,  Abby Trotter    Abby Trotter  Executive Director  Life Science Tennessee  New address: 618 Church Street, Suite 210   Nashville, Tennessee 37219  O: 615‐242‐8856   atrotter@lifesciencetn.org    1 Board of Directors Ted Townsend Chairman University of Memphis Josh Brown Past-Chairman Pfizer Glenn Perdue, MBA, AVA, CFFA, CLP Treasurer Kraft Analytics, LLC Alan R. Bentley Secretary Vanderbilt Office of Technology Transfer & Commercialization Tom Ballard PYA Dean Hughes Smith & Nephew Paul Fitzpatrick, Advanced Catheter Therapies/Device Technologies Kayla Graff SweetBio Kyle Kamrath Vertex Pharmaceuticals Jessica Monroe Johnson & Johnson Pete Nelson AgLaunch Julie Lampley Butler Snow Dr. Stephen White St. Jude Children’s Research Hospital Brian Laden Appello Pharmaceuticals Steve Bares Memphis Bioworks Hunter Rost Waller, Lansden, Dortch & Davis, LLP Shawn Glinter Pendant Bioscience Judsen Schneider Nashville BioSciences Teddy Van Opstal President, Academic Alliance Vanderbilt University Giri Kumar Chandaka President, Academic Alliance UT Health Science Center Kate Halter Co-President, Academic Alliance University of Tennessee Justin Westerfield Co-President, Academic Alliance University of Tennessee October 18, 2019 Mr. Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Director Roberts: Life Science Tennessee extends its gratitude to the Division of TennCare for the opportunity to comment on the draft of TennCare II Demonstration Waiver Amendment 42. Life Science Tennessee is the premier advocacy organization representing the life science industry in the state. Our members include companies, research institutions, academic researchers and economic development organizations with a unique mission to deliver life-enhancing therapeutics, medicines, food and energy to Tennesseans, while also improving Tennessee’s position as a leader in life science technology and innovation. Life Science TN applauds efforts by the State of Tennessee and members of the Tennessee General Assembly to become a strong supporter of innovation that will improve patient access to life-saving drugs and therapies, including in our rural communities, as well as support of agricultural advances. We greatly value our partnership. Tennessee’s life science industry employs more than 34,000 people in more than 1,500 business establishments, according to the 2018 BIO industry report. Tennessee’s research universities are especially focused in the biosciences relative to other states with $750 million in bioscience academic R&D in 2014 accounting for 69 percent of all academic research in Tennessee. In this vein we write to express our concern regarding the Waiver draft. Much of our concern is technically outlined by our national industry partner the Biotechnology Innovation Organization (BIO) in their public comment letter also dated October 18, 2019. Our primary concern lies with the waiver’s support and defense of a closed formulary model for TennCare pharmacy benefits. To begin, government actuaries project the share of health care spending attributable to drugs will continue to grow in line with overall health care costs for at least the next 10 years. In Tennessee, drug spending composes approximately 10 to 11% of the overall TennCare budget and that number has remained fairly constant. Life Science Tennessee 217 Fifth Avenue North, Suite 200 Nashville, TN 37219 615-242-8856 info@lifesciencetn.org Page 2 of 2 Mr. Gabe Roberts/Division of TennCare In addition to BIO’s comments, we offer as well that new drug therapies can limit the growth of health care costs overall by effectively treating patients and keeping them out of more costly provider settings, which account for the largest amount of TennCare spending. Further, Life Science TN submits that many companies in the state research and develop life-saving drugs and therapies, while providing high-paying jobs to Tennesseans. Ours is an important and growing field for the Tennessee economy. We ask that you oppose proposals that would impede these companies’ abilities to bring new cures to patients, as the Waiver suggests in its comments regarding the FDA’s accelerated pathway approval process, for example. Life Science Tennessee welcomes further discussion about the use of innovative models to ensure efficient and effective care for our State’s TennCare population and we welcome the opportunity discuss this further. Sincerely, Abby Trotter Executive Director atrotter@lifesciencetn.org Life Science Tennessee 200 Fourth Avenue North, Mezzanine Nashville, TN 37219 615-242-8856 info@lifesciencetn.org BY ELECTRONIC DELIVERY October 18, 2019 Mr. Gabe Roberts Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 RE: TennCare II Demonstration Waiver Amendment 42 Dear Director Roberts: The Biotechnology Innovation Organization (BIO) appreciates the opportunity to comment on the recently filed TennCare II Demonstration Waiver Amendment Request that seeks, among other things, a waiver of compliance with essential provisions of §1927 of the Social Security Act (SSA). We hope the state will abandon this attempt and work with biopharmaceutical manufacturers to accomplish the goals of stability and predictability in the Medicaid pharmacy budget without jeopardizing patient care. BIO is the world’s largest trade association representing biotechnology companies, academic institutions, state biotechnology centers, and related organizations across the United States and in more than thirty other nations. BIO’s members develop medical products and technologies to treat patients afflicted with serious diseases, to delay the onset of these diseases, or to prevent them in the first place. In that way, our members’ novel therapeutics, vaccines, and diagnostics yield not only improved health outcomes, but also reduced health care expenditures due to fewer physician office visits, hospitalizations, and surgical interventions. While BIO appreciates the need for the State to explore ways it can achieve savings and stability in Medicaid expenditures, we have deep reservations regarding a block grant proposal that is primarily driven by cost with little consideration for patient access to necessary, quality care. We do not believe a block grant proposal that seeks to completely overhaul financing in a way that will undermine the quality of care, should be considered as part of a waiver amendment. Rather, such fundamental changes likely require applying for a new waiver demonstration, as is permitted by the authorizing statute, Public Chapter 481 (HB 1280), which would allow for more extensive deliberation and examination of the intended modifications to the TennCare II program. However, the main focus of BIO’s comments centers on the intention to waive §1927 of the SSA in order to adopt a “commercial-style” closed formulary, leaving many drug classes with only one drug per formulary class; a scheme the Centers for 1 Director Roberts, BIO Comments October 18, 2019 Page 2 of 11 Medicare and Medicaid Services (CMS) has already rejected soundly in its response to Massachusetts’ similar attempt in 2018. In order to appropriately manage drug expenditures, we believe the state should focus on alternative, innovative payment strategies based on value that balance patient care and positive health outcomes against the needs and limitations of the states’ finite resources. Our specific comments on the TennCare II Demonstration Waiver Amendment 42 with respect to the proposal on the waiver of §1902(a)(54) of the SSA, insofar as it incorporates §1927 are summarized as follows: • • • CMS has already rejected a nearly identical proposal requested by Massachusetts because it violates existing SSA law; A closed formulary hinders access and jeopardizes the quality of care of the most vulnerable patients, especially those with rare, life-threatening diseases; Denial of access to drugs approved through one of FDA’s expedited programs (accelerated approval) harms the most vulnerable patients; and, Tennessee can achieve better financial predictability in its pharmacy program through alternative payment mechanisms that emphasize value and outcomes. BIO’s more extensive comments are below. CMS has already rejected a nearly identical proposal requested by Massachusetts because it violates existing SSA law In 2017, the Commonwealth of Massachusetts proposed a plan to reform its Medicaid pharmacy program to waive §1902(a)(54) of the SSA, insofar as it incorporates §1927, in an attempt to circumvent the Medicaid drug formulary requirements of §1927(d)(4). It proposed a closed formulary with least one drug per class, with the intent to exclude drugs approved through the FDA’s accelerated approval process. Both policies were firmly rejected by CMS, indicating that a state cannot simply opt out of §1927 and not provide access to “covered outpatient drugs” for which a manufacturer has a signed National Rebate Agreement.1 The same day that CMS responded to the Massachusetts waiver amendment, the agency issued “State Release No. 185,” which underscored the fact that drugs approved through the FDA’s expedited approval processes “must be covered by state Medicaid programs, if the drug meets the definition of “covered outpatient drug” as found in Section 1927 of the Social Security Act”2 and the Manufacturer has a signed Medicaid National Rebate agreement. While the specific details of the Tennessee proposed Medicaid drug coverage reforms remain vague, one thing is clear, the Department’s stated intent to waive §1927 of the SSA in order to adopt a “commercial-style” closed formulary and 1 2 CMS letter to Asst. Secretary Tsai, MassHealth, June 27, 2018. CMS State Release No. 185, June 27, 2018. 2 Director Roberts, BIO Comments October 18, 2019 Page 3 of 11 circumvent the formulary requirements of §1927(d)(4). The waiver amendment proposal also indicates it would deny access to new innovative drugs approved through the FDA accelerated approval process, because “many of them have not yet demonstrated actual clinical benefit and have been studied in clinical trials using only surrogate endpoints.” Accelerated approval is reserved for drugs that address serious or life-threatening diseases with limited or no treatment options and, importantly, are proven safe and effective by the same rigorous evidentiary standards used by FDA to approve all other medicines.3 Given the nearly identical components of the Tennessee approach to Massachusetts, we urge the State to abandon this attempt and work with manufacturers and CMS on other alternatives, which are discussed later in this letter. The Medicaid rebate provisions of the SSA represent a carefully balanced compromise made by Congress to ensure the Government has access to the lowest available price for covered outpatient prescription medicines – via a statutorily mandated rebate – while also ensuring that manufacturers’ products would be accessible to Medicaid recipients if medically necessary and subject to statutorily defined access restrictions. The Medicaid program is guaranteed a manufacturer’s “best price,” as defined in statute, and in addition, receives an inflationary rebate to protect states from price increases that rise above the consumer price index. Furthermore, because states can already negotiate rebates higher than what is statutorily mandated it is dubious that states can negotiate better rebates by opting out of the statute. According to the Georgetown University Health Policy Institute, “Medicaid obtains rebates that are far larger than those in Medicare Part D and in private insurance.”4 According to the June 2019 Report to Congress, the Medicaid and CHIP Payment and Access Commission noted that the Medicaid program received $34.9 billion in rebates from pharmaceutical manufacturers in 2017.5 This resulted in a net reduction in pharmacy spend of 54.5%.6 The Medicare Part D program only received 19.9% in rebates in 2016.7 In short, the Medicaid Drug Rebate Program works to achieve both the intended goals, ensuring patient access to much needed medicines at the lowest possible prices. SSA § 1115 Does Not Authorize the Proposed Waiver Under SSA § 1115(a), a state’s proposed waiver must set forth an “experimental, pilot, or demonstration project,” that, in the judgment of the Secretary, is “likely to assist in promoting the objectives of title XIX [i.e., the 21 U.S.C. §356(e)(2). “How to Strengthen the Medicaid Drug Rebate Program to Address Rising Medicaid Prescription Drug Costs,” Issue Brief, Georgetown University Health Policy Institute, January 2019. 5 Report to Congress, MACPAC, June 2019. https://www.macpac.gov/publication/june-2019-report-tocongress-on-medicaid-and-chip/, Accessed: October 9, 2019. 6 Id. 3 4 3 Director Roberts, BIO Comments October 18, 2019 Page 4 of 11 Medicaid program].”8 A waiver of compliance with SSA § 1927 would fail to satisfy these criteria. In the first instance, the State has not specified a research proposition that it seeks to test. It proposes only to cut costs by restricting coverage of covered outpatient drugs that it would otherwise be required to cover under SSA § 1927. As the Court of Appeals for the Ninth Circuit has emphasized, such “[a] simple benefits cut, which might save money but has no research or experimental goal, would not satisfy th[e] criteria [of] ha[ving] a research or demonstration value.”9 SSA § 1115 demonstration projects must test innovative approaches aimed at furthering the objectives of the Medicaid program, for example, by enhancing quality of care or promoting efficient administration. A demonstration project may not operate as a mere benefit cut with no actual experimental value. Additionally, a waiver of compliance with SSA § 1927 would fail to promote the objectives of title XIX, which was enacted by Congress in order to provide medical care to the needy and medically needy.10 By denying access to otherwise-covered and potentially life-saving therapies, the State would do precisely the opposite – strip away medical care for the needy and medically needy. Such a waiver would also fail to promote Congress’s clear objectives in enacting SSA § 1927 in particular – indeed, it would contradict these objectives. Congress enacted SSA § 1927 in order to guarantee that “[s]tates that elect to offer prescription drugs … cover all the products of any manufacturer that agrees to provide price rebates.”11 If CMS were to approve a waiver of compliance that enables a state to avoid its drug coverage obligations under SSA § 1927, the agency would undermine the primary objective of SSA § 1927, as stated by Congress itself. On top of this, the State would fail to ensure that “Medicaid beneficiaries have access to the same range of drugs that the private patients or their physicians enjoy,” as intended by Congress.12 CMS confirmed this understanding in its June 27, 2019 letter to the Commonwealth of Massachusetts. A Closed Formulary hinders access and jeopardizes the quality of care of the most vulnerable patients BIO has grave concerns that a waiver of compliance with SSA § 1927’s coverage requirements would harm patient health by restricting access to medically necessary drugs. Indeed, in covering as few as one drug per therapeutic class, Tennessee would seriously jeopardize the health of many patients. Below we highlight only a few examples in which a closed formulary is detrimental to patients. Despite the availability of a variety of drug treatments for epilepsy, approximately 30% to 40% of all epilepsy patients still do not have the ability to adequately manage SSA § 1115(a). Beno v. Shalala, 30 F.3d 1057, 1069 (9th Cir. 1994). 10 Staff of H. Comm. on Ways and Means, 89th Cong., Summary of Major Provisions of H. R. 6675, The “Social Security Amendments of 1965” 1 (Comm. Print 1965). 11 Id. 12 H. Rep. No. 101-881, at 96-97 (1990). 8 9 4 Director Roberts, BIO Comments October 18, 2019 Page 5 of 11 their seizures,13 and those patients who are able to manage their condition often must take up to three to five drugs at a time to control their seizures. According to the Centers for Disease Control and Prevention (CDC), there are roughly 74,000 people in Tennessee suffering from epilepsy, 10,000 of which are children.14 If Tennessee were to limit coverage to a single drug in a therapeutic class, many epilepsy patients would be left without adequate therapy to manage their condition. Furthermore, access to necessary medications for appropriate care is especially important for adults and children with chronic conditions such as chronic lower respiratory disease, which often requires multiple medications to treat. This disease that includes COPD and asthma is the fourth leading cause of death in the United States, with over 160,000 deaths in 2016.15 According to the CDC, approximately 517,735 Tennessee adults (10%)16 were affected by asthma. Additionally, Tennessee Department Health states that about 86,911 children aged 0-17 were living with asthma in 2017.17 Given the prevalence of COPD and asthma in Tennessee, a drug formulary should accommodate standard medical science, accepted treatment guidelines and support new innovations to safeguard the medication needs of the State’s population. A commercial-style closed formulary design with one drug per class policy would not ensure patient access to current and innovative therapies for the appropriate treatment of respiratory diseases. This is also true for people living with HIV. HIV treatments are not one-size fits all, and often anti-retroviral therapy (ART) options cannot be easily substituted. Health care providers work closely with patients to select treatment with great specificity for each patient. Patients often respond differently to the same ART. People living with HIV rely on open formularies because the effective treatment of HIV is highly individualized and accounts for a patient’s size, gender, treatment history, viral resistance, coexisting illnesses, drug interactions, immune status, and side effects. In fact, the HHS clinical treatment guidelines18 state that, “[g]iven the wide array of treatment options, individualizing treatment with patient involvement in decision making is the cornerstone of treatment planning and therapeutic success.”19 The guidelines also recognize that “[i]t is important to consider the NIH Epilepsy Data: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/HopeThrough-Research/Epilepsies-and-Seizures-Hope-Through, Accessed: October 9, 2019. 14 https://www.cdc.gov/epilepsy/data/index.html Accessed: October 9, 2019 13 CDC 2017 Most recent Asthma Data: https://www.cdc.gov/asthma/most_recent_data.htm Accessed October 7, 2019. 17 Tennessee Department of Health; Healthy Homes Asthma; https://www.tn.gov/health/cedep/environmental/healthy-homes/hh/asthma.html Accessed October, 2019 16 DHHS Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, NIH.gov https://aidsinfo.nih.gov/guidelines Accessed on 6/26/2019 19 HHS, Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, p. 183, https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0. Accessed October 13, 2017. 18 5 Director Roberts, BIO Comments October 18, 2019 Page 6 of 11 patient’s daily schedule; patient tolerance of pill number, size and frequency; and any issues affecting absorption.”20 Medical challenges for people living with HIV also include an increased risk for, and prevalence of, comorbidities that require additional drug treatment such as depression and substance use disorders,21 as well as cardiovascular disease, hepatic and renal disease, osteoporosis, metabolic disorders, hypertension, hyperlipidemia, and endocrine disease and several non–AIDS-defining cancers. 22,23,24,25 Clinically significant drug interactions have been reported in 27 to 40 percent of HIV patients taking antiretroviral therapy requiring regimen changes or dose modifications.26 Accordingly, we must focus on maintaining access to all ART instead of limiting the number of HIV medicines. Closing the TennCare formulary would restrict access to high quality treatment for many people living with HIV at a time when ART can lower viral load to non-detectable levels. This means that the virus cannot be transmitted to others. The types of short-sighted policies, such as a closed formulary, can have poor public health consequences, and can result increased costs elsewhere in the budget. Studies show that restricting access to drugs through closed formularies results in non‐adherence or poor adherence to prescribed medication regimens, worsened health outcomes and hospitalizations, not to mention other costs to the state such as additional costs to the state correctional system. 27,28,29,30 It is obvious that, in many therapeutic classes, such a culling of drugs from drug classes would leave some Medicaid beneficiaries far worse off. Providing access to a wide variety of drug agents remains the cornerstone to improved patient care as one Id. CDC, Medical Monitoring Project, United States, 2013 Cycle (June 2013–May 2014 22 Joel Gallant, Priscilla Y Hsue, Sanatan Shreay, Nicole Meyer; Comorbidities Among US Patients With Prevalent HIV Infection—A Trend Analysis, The Journal of Infectious Diseases, Volume 216, Issue 12, 19 December 2017, Pages 1525–1533, https://doi.org/10.1093/infdis/jix518 23 Rodriguez-Penney, Alan T. et al. “Co-Morbidities in Persons Infected with HIV: Increased Burden with Older Age and Negative Effects on Health-Related Quality of Life.” AIDS Patient Care and STDs 27.1 (2013): 5–16. PMC. Web. 21 June 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3545369/ 24 Joint HHS, CMCS, HRSA, and CDC Informational Bulletin, Opportunities to Improve HIV Prevention and Care Delivery to Medicaid and CHIP Beneficiaries, p. 9 (December 1, 2016), https://www.medicaid.gov/federal-policy-guidance/downloads/cib120116.pdf. Accessed October 13, 2017. 25 Joel Gallant, Priscilla Y Hsue, Sanatan Shreay, Nicole Meyer; Comorbidities Among US Patients With Prevalent HIV Infection—A Trend Analysis, The Journal of Infectious Diseases, Volume 216, Issue 12, 19 December 2017, Pages 1525–1533, https://doi.org/10.1093/infdis/jix518 26 Evans-Jones JG et al. Clin Infect Dis 2010;50:1419–1421; Marzolini C et al. Antivir Ther 2010;15:413–423. 27 Happe LE, Clark D, Holliday E, Young T. A systematic literature review assessing the directional impact of managed care formulary restrictions on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization. J. Managed Care Spec Pharm. 2014;20(7):677‐84. 28 Zullig, LL, Bosworth, H, Engaging patients to optimize medication adherence. NEJM Catalyst, May 14, 2017. 29 Seth A. Seabury, et al., Formulary restrictions on atypical antipsychotics: impact on costs for patients with schizophrenia and bipolar disorder in Medicaid, 20 AM. J. MANAGED CARE e52 (2014). 30 Yujin Park, et al., “The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systemic Literature Review,” Journal of Managed Care Pharmacy. 2017 Aug; 23(8):893-901. 20 21 6 Director Roberts, BIO Comments October 18, 2019 Page 7 of 11 formulary agent may not produce the intended therapeutic outcome across all patient types. Also, side effect profiles vary across all patient types and a closed formulary design may lead to therapy discontinuation due to side effects. These concerns are even more heightened as science and innovation moves toward personalized medicine, particularly in rare and chronic diseases. Moreover, the State’s assertion that a truly “closed formulary” would offer Medicaid beneficiaries coverage comparable to that of Medicare Part D beneficiaries is inaccurate. Unlike TennCare beneficiaries, Medicare Part D beneficiaries have a choice among multiple coverage options, with transparency into the particular drugs included on any individual formulary and protections against mid-year formulary changes. As a result, Medicare Part D beneficiaries can choose the formulary that best suits their medical needs with reasonable certainty that they will have such coverage over the next year. And, if their needs change, they can choose a new Part D plan during the annual open enrollment period. In addition, the Part D program has an exceptions and reconsideration process that provides access to off-formulary therapies, as well as six protected classes of drugs, for which Part D plans must include all, or substantially all, drugs in the class on-formulary — namely, the classes of anti-convulsants, anti-depressants, anti-psychotics, anti-neoplastics (oncology), immunosuppressants, and anti-retrovirals (HIV/AIDS). TennCare has described no such protections in its Waiver Amendment request. It is likewise the case that patients who obtain coverage through the health insurance exchanges have the ability to choose plans with a formulary that are best suited to their individual needs, and can also their plan during the annual open enrollment period as their health care needs change. In addition, these patients would have access to an exceptions process to obtain their medically necessary medications. The suggestion that TennCare would maintain a high quality of care while denying access to many medically necessary drugs, is dubious at best. The State did not even specify in its proposal whether patients might have access to an exceptions process. Whether there is an exceptions process or not, there are likely to be delays in treatment for thousands of Tennesseans. Delays in access to treatment have shown to lead to worse patient outcomes. A recent study assessing time to treatment initiation (TTI) for cancer patients showed that increased TTI was associated with worsened overall survival for stages I and II breast, lung, renal, and pancreas cancers, and stage II colorectal cancers.31 Khorana AA, Tullio K, Elson P, et al. Increase in time to initiating cancer therapy and association with worsened survival in curative settings: A U.S. analysis of common solid tumors. Journal of Clinical Oncology 2017 35:15_suppl, 6557-6557. 31 7 Director Roberts, BIO Comments October 18, 2019 Page 8 of 11 Denial of Access to Drugs Approved through FDA’s Expedited Approval Pathway Harms the Most Vulnerable Patients The State proposes to exclude drugs approved through FDA’s expedited approval process “from its formulary until market prices are consistent with prudent fiscal administration or the state determines that sufficient data exist regarding the cost effectiveness of the drug.”32 CMS notes in State Release 185 that these drugs must be covered by the Medicaid program if there is a signed Medicaid National Rebate Agreement, but it also reaffirms that these drugs go through the same rigorous approval as drugs through the traditional approval process.. State Release 185 notes, “Section 506(c) of the FFDCA allows the FDA to grant accelerated approval to a drug for a serious or life-threatening disease or condition. Part of the criteria for accelerated approval under section 506(c) is a demonstrated effect on either: “a. A surrogate endpoint that is reasonably likely to predict a clinical benefit, taking into account severity, rarity, or prevalence of the condition and the availability or lack of alternative treatments, or b. A clinical endpoint that can be measured earlier than irreversible morbidity or mortality, that is reasonably likely to predict an effect on irreversible morbidity or mortality or other clinical benefit, taking into account severity, rarity, or prevalence of the condition and the availability or lack of alternative treatments. “Drugs granted accelerated approval by FDA under the process described in 506(c) of the FFDCA are approved under section 505(c) of the FFDCA and must meet the same statutory evidentiary standards for safety and effectiveness as those granted traditional approvals. See section 506(e)(2) of the FFDCA. Thus, as noted above, at the time a product is granted accelerated approval, FDA has based such an approval on a determination that the drug has an effect on a surrogate endpoint that is reasonably likely to predict clinical benefit or on a clinical endpoint other than survival or irreversible morbidity.”33 BIO strongly objects to the exclusion of such categories of drugs in Medicaid not just because the statute and regulations demand it, but because these drugs must go through the same rigorous clinical review as other drugs, and they provide treatment for unmet medical needs. Furthermore, the FDA, the scientific community, and Congress,34 have all deemed surrogate endpoints as an appropriate marker of clinical efficacy in certain diseases. In the case of diseases that take course over a long period of time (e.g., Alzheimer’s Disease or a respiratory disease), surrogate endpoints are critical because researchers cannot feasibly study the ultimate, longterm impact on clinical outcomes through clinical trials – to do so would require years, 32 33 34 TennCare II Demonstration Waiver Amendment 42 proposal, September 2019. State Release 185, CMS, June 27, 2018. Food Drug Administration Safety and Innovation Act, §901. 8 Director Roberts, BIO Comments October 18, 2019 Page 9 of 11 or even decades, of study. By attempting to limit Medicaid beneficiaries’ access to therapies for which only surrogate endpoints have been reported, Tennessee would deprive patients who are already suffering from certain conditions of access to important therapy options approved by the FDA as safe and efficacious. For over 25 years, FDA and Congress have both been clear in affirming that accelerated approval does not dilute or otherwise compromise FDA’s approval standards. FDA similarly responded to concerns that the accelerated approval process was inconsistent with the substantial evidence requirement of section 505(d) of the Food, Drug, and Cosmetic Act (21 U.S.C. § 355(d)): “Approval under this rule requires ... that the effect shown be, in the judgment of the agency, clinically meaningful, and of such importance as to outweigh the risks of treatment. This judgment does not represent either a "lower standard" or one inconsistent with section 505(d) of the act, but rather an assessment about whether different types of data show that the same statutory standard has been met.”35 The State appears to suggest that Tennessee can determine the safety and clinical efficacy of a drug in a manner superior to that of the FDA, which is considered the worldwide gold standard in the review and efficacy of drugs. Tennessee is attempting to thwart the goals of the Federal Food, Drug and Cosmetic Act (FDCA), which tasks FDA with applying its expertise to speed the development of medicines for serious diseases while maintaining its rigorous approval standards. As explained in the extensive findings and sense of Congress provisions of the Food Drug Administration Safety and Innovation Act, §901: “[FDA] serves a critical role in helping to assure that new medicines are safe and effective. Regulatory innovation is 1 element of the Nation’s strategy to address serious and life-threatening diseases or conditions by promoting investment in and development of innovative treatments for unmet medical needs.” As specified by Congress, the FDA may consider use of accelerated approval to “a product for a serious or life-threatening disease or condition . . . upon a determination that the product has an effect on a surrogate endpoint that is reasonably likely to predict clinical benefit, or on a clinical endpoint that can be measured earlier than irreversible morbidity or mortality, that is reasonably likely to predict an effect on irreversible morbidity or mortality or other clinical benefit, taking into account the severity, rarity, or prevalence of the condition and the availability or lack of alternative treatments.”36 35 57 Fed. Reg. at 58944. 36 21 U.S.C. § 356(a)(1). 9 Director Roberts, BIO Comments October 18, 2019 Page 10 of 11 Drugs approved through this accelerated pathway are subject to a demanding standard of review —demonstration of “substantial evidence” of effectiveness.37 In fact, studies have found that certain drugs reviewed under the accelerated approval processes have offered greater medical gains than drugs reviewed through the FDA’s traditional, lengthier process.38 Importantly, for drugs granted accelerated approval, post-approval confirmatory trials or studies are required as part of the regulatory process to verify and describe the anticipated clinical benefit.39 If the confirmatory trial fails to verify benefit, the FDA has the authority to withdraw approval and has done so when needed.40 BIO is also concerned about the statement in the proposal that the state would only consider coverage of these valuable and necessary medications when the market prices become “consistent with prudent fiscal administration” or when the state determines that “sufficient data on cost effectiveness” exists. Such vague requirements risk delaying or denying access to valuable medications that may be a patient’s only option and can ultimately help to avoid unnecessary healthcare system costs that arise from untreated conditions. As noted, these drugs treat rare, serious, or life-threatening diseases; most of which are chronic and can cost the State [and patients] a great deal more over the lifetime of the disease. Value assessments in current cost-effectiveness models are seriously lacking and are not representative of the full set of considerations that go into determining the value of a particular medicine or course of treatment. Further, the Medicaid law and regulations specifically do not include a cost-effectiveness standard as a condition of coverage. Tennessee can achieve better financial predictability in its pharmacy program through alternative payment mechanisms that emphasize value and outcomes. Moreover, BIO believes that Tennessee would be better served to seek a State Plan Amendment or waiver amendment that would allow the State the flexibility to negotiate voluntary alternative payment models that emphasize value, quality, and outcomes. BIO believes that the success of the voluntary, innovative contracting approaches such as those approved in Oklahoma, Michigan, Colorado, and most recently Texas, pending CMS approval of its state plan amendment41, as well as other states have the potential to demonstrate beneficial outcomes, stability in financing, and continued future innovation. 21 U.S.C § 355(d)(5). Chambers, et al., Drugs Cleared Through the FDA’s Expedited Review Offer Greater Gains Than Drugs Approved by Conventional Process, Health Affairs Vol. 36, No. 8, 2017. 39 FDA. Guidance for Industry: Expedited Programs for Serious Conditions – Drugs and Biologics. May 2014. 40 FDA. Delivering Promising New Medicines Without Sacrificing Safety and Efficacy. FDA Voices: Perspectives from FDA Leadership and Experts. August 2019. 41 https://hhs.texas.gov/sites/default/files/documents/services/health/medicaid-chip/state-plan/texasstate-plan-medical-assist-amendment-oct-2019.pdf 37 38 10 Director Roberts, BIO Comments October 18, 2019 Page 11 of 11 • • For example, some contracts are strictly linked to outcomes. If a drug does not produce certain metrics, such as a reduction in hospitalizations by patients using the drug, the manufacturer would receive a reduced payment or no payment. Other examples such as an amortized payment contract, or pay-over-time, would allow for the drug to be delivered up front for the patient and then the state would stretch out the payment over a set period of payments, with payments that could be tied to a health outcome (referred to as milestone payments); or alternatively, the subscription model that in certain types of disease states can provide unlimited amounts of a drug for established payments over set period of time. These options can provide more predictable financing for the appropriate disease states. BIO strongly supports innovative negotiation between states and biopharmaceutical companies, which will, in turn, help ensure patient access to necessary therapies. We believe that value-, outcomes- or indication-based arrangements, and alternative payment models, all have merits to both states and biopharmaceutical companies. BIO and the biopharmaceutical industry look forward to working with Tennessee to help the state understand the variety of arrangements that exist and flexibility they can provide to ensure new models can be developed as health care evolves and new medications are developed. *** Thank you for the opportunity to submit comments on the TennCare Waiver amendment proposal. We strongly urge the state to work with the biopharmaceutical industry to ensure new policies do not severely jeopardize patient access to care, given our belief that Tennessee can achieve its objectives without any waiver amendment of §1927. Should you have any questions, please do not hesitate to contact me at (202) 962-9200 or at jgeisser@bio.org. Sincerely, /s/ Jack Geisser Senior Director Healthcare Policy, Medicaid, and State Initiatives 11 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Brian Keller Tuesday, October 15, 2019 3:26 PM PUBLICE NOTICE TENNCARE Lisa Primm; Susan Mee [EXTERNAL] Amendment 42 - Disability Rights Tennessee Comment DRT Block Grant Comment FINAL.PDF   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom it May Concern:     Attached is Disability Rights Tennessee’s comment on Amendment 42. We are happy to discuss the proposal or answer  any questions you may have about our comment.    Brian D. Keller, Esq.  Public Policy and Voting Attorney  (615)732‐6980  2 International Plaza, Suite 825    Nashville, TN 37217    This communication contains information from Disability Rights Tennessee which may be confidential and/or privileged.  The information is intended to be for the use  of the individual(s) or entity(s) named as recipients above.  If you are not the intended recipient, please destroy this correspondence and be aware that any  disclosure, copying, distribution or use of the contents of this information is prohibited.  If you received this communication in error, please immediately notify the  sender.               This communication contains information from Disability Rights Tennessee which may be confidential and/or privileged.  The information is intended to be for the use of the individual(s) or entity(s) named as recipients above. If you are not  the intended recipient, please destroy this correspondence and be aware that any disclosure, copying, distribution or  use of the contents of this information is prohibited. If you received this communication in error, please immediately  notify the sender.      1 Jonathan Reeve From: Sent: To: Subject: Attachments: lynnessex@aol.com Friday, October 18, 2019 7:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant TennCare.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   1 Dear TennCare Officials, TennCare is important to my family. It provides comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely, Lynn Essex   Jonathan Reeve From: Sent: To: Subject: Attachments: marian.t.ott@gmail.com Thursday, October 17, 2019 10:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Revised Comments from the League of Women Voters October 2019 LWVTN Revised Testimony on TennCare amendment 42.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please accept the attached as a replacement for the version sent yesterday. This testimony corrects typos and  a factual misstatement.    Thank you    Marian Ott (she/her)  President        1 LWV-TN Comments on TennCare Amendment 42 The following remarks and recommendations are submitted on behalf of the League of Women Voters of Tennessee (LWV-TN) in response to the request for public comment by the Division of TennCare regarding the TennCare II Demonstration, Project No. 11-W-00151/4, Amendment 42, also known as the Block Grant Waiver.1 SUMMARY The LWV-TN believes that Waiver Amendment 42 has the potential to harm current and future TennCare recipients and threatens the financial viability of Tennessee’s Medicaid program. While the current waiver amendment addresses previous concerns about federal funding elasticity to accommodate future growth in TennCare enrollment, it raises new concerns about overbroad state flexibility to limit scope, amount, and duration of existing benefits and to restrict the cost and choice of covered medications. As currently written, the waiver amendment fails to describe acceptable mechanisms for public oversight and accountability and creates significant financial risk for the state. Moreover, features of Amendment 42 conflict with federal law and policy and if approved would trigger prolonged litigation, at high cost to both federal and state governments.2 Most importantly, this amendment does not address Tennessee's most urgent health issues: (1) rising numbers of Tennesseans without health coverage or comprehensive health care access resulting in catastrophic problems for individual and public health; and (2) ongoing rural hospital closures due in part to high rates of uncompensated care and bad debt. The League of Women Voters opposes changes to federal financing of TennCare proposed in Amendment 42 for the following reasons: ➢ Unnecessarily risky and complex policy changes that focus on program financing rather than program outcomes Changing federal financing of Tennessee’s Medicaid program from a guaranteed entitlement to a capped allotment (block grant) would incur potentially higher costs to our state government, while creating health risks for vulnerable people who currently qualify for TennCare (children, custodial adults, people with disabilities, and elderly nursing home residents).2,3,4 Under the proposed block grant waiver, if TennCare expenditures were to exceed baseline costs for core Medicaid services calculated under the proposed new formula, the state would be responsible for the full excess amount. This could result in cuts to current benefit levels, or the appropriation of additional state funding unmatched by the federal government. It could also LWV-TN Comments on TennCare Amendment 42 have spillover effects for populations or services not initially included in the block grant (e.g., individuals with intellectual disabilities, children in foster care, dual Medicaid-Medicare eligibles, DSH payments to hospitals for uncompensated care, outpatient pharmacy benefits). Any year in which the state does not spend the entire federal block grant, the state would retain 50 percent of unspent federal funds provided by the block grant that could be reinvested in health-related supports for unspecified target populations. This funding arrangement creates a perverse incentive for seeking reductions in the scope, amount and duration of current TennCare services with minimal, if any, oversight from the federal government. Despite the waiver proposal’s assurance that there will be “no reductions in who is eligible for or what benefits are currently provided in TennCare,” it is likely that significant savings would be realized only by tightening current benefits or reimbursements for MCOs or providers. The block grant request is based on the premise that TennCare is an extremely efficient program in comparison to other state Medicaid programs and the “savings” TennCare provides to the federal government are due to that greater “efficiency,” which has been accomplished over many years through managed care instead of fee-for-service health care financing. TennCare delegates responsibility for care coordination to managed care organizations and often relies on non-profit organizations across the state to supplement case management and wrap-around services that many other state Medicaid agencies themselves provide. Other states offer broader health services than Tennessee and cover additional populations. Tennessee this year became the last state in the union to provide Katie Beckett waiver supports to medically fragile children with complex health problems who would otherwise not meet state Medicaid income eligibility criteria, and Tennessee remains one of only a handful of states that does not provide dental coverage to adults. While the Amendment funding formula makes allowances for changes in numbers of Tennesseans eligible for the program and indexes the per capita block grant amount to inflation, TennCare acknowledges that in order to maintain budget neutrality, current benefits may need to be restricted and has requested broad flexibility to limit services “in scope, amount, or duration” as well as the flexibility to reduce pharmacy costs by limiting prescription drug options on the TennCare formulary. Meanwhile Tennessee remains in the lowest quartile of states in the USA with respect to significant population health indicators, including maternal mortality, low birth weight babies, adult obesity, incidence and prevalence of diabetes and cardiovascular disease, and cancer mortality rates.5 Although TennCare is not solely responsible for these poor public health outcomes, our state's persistently low health rankings call into question whether Tennessee is actually spending enough on caring for low-income people. While Amendment 42 characterizes the state's retention of 50% of the amount it "saves" the federal government as a plus, it could also be argued that instead the Amendment leaves our state's Medicaid funding glass half empty. The League of Women Voters of Tennessee believes that the Amendment's emphasis on cost savings is sadly misplaced and even creates a perverse incentive to restrict important services LWV-TN Comments on TennCare Amendment 42 and options. TennCare should be focused instead on demonstrating the value or costeffectiveness of the services provided to covered populations based on health outcomes, and rewarded for outcome improvements. Before launching this experimental waiver, there needs to be a thorough analysis of where TennCare "efficiencies" are currently being achieved in comparison with other state Medicaid programs, as well as an assessment of how health outcomes of TennCare recipients compare with health outcomes of Medicaid recipients in states with higher per-capita costs. This is the only way that Tennessee, and CMS, can fully determine if this block grant proposal has the potential for being a better deal. ➢ Unspecified metrics to assess impact of policy changes on TennCare recipients Amendment 42 asserts that the State's evaluation will focus on “1) the extent to which TennCare expenditures grow under the block grant, as compared to the growth of Medicaid expenditures nationally, and 2) the extent to which the interventions implemented by the State under the block grant are successful in improving access to care and health outcomes for members.” However, no measures are currently specified for monitoring changes in health outcomes or health care access. The waiver proposal notes only that the state intends to contract with an independent evaluator to develop a plan for evaluating these goals and will identify appropriate performance measures to assess the impact of the demonstration in consultation with this evaluator and CMS (p. 23). The League of Women Voters of Tennessee contends that, at a minimum, TennCare should provide CMS with baseline data on the TennCare population, using both process measures and outcome measures, during the same three-year period (2016-2018) on which average TennCare expenditures are based in the block grant waiver proposal. TennCare should also articulate the metrics it plans to use to evaluate the impact of the proposed demonstration project before any approval is considered. Metrics proposed should enable comparison of TennCare performance and outcomes under the block grant (if approved) with performance and outcomes before implementation of this block grant waiver. And, as noted earlier, the metrics proposed and approved should allow for ongoing comparison of performance and outcomes between TennCare and other state Medicaid programs, both those that continue traditional Medicaid funding and those that have expanded Medicaid services and covered populations. Performance or process measures might include tracking the percentage of those eligible who are enrolled in TennCare and who maintain the continuity of their coverage; frequency of claim denials and rates of appeals; attainment of maternity and pediatric care benchmarks; attainment of benchmarks tied to current and future episodes of care payments; utilization of preventive care, primary care, specialty care, and mental/behavioral health care including treatment for substance use disorders. Monitoring of the state’s ability to maintain adequate provider networks is also important. Many providers have expressed concern about returning to a TennCare system in which patients face arbitrary limits on duration and scope of services and bare-bones formularies requiring the initiation of more frequent appeals for medically warranted exceptions. Outcome measures might include birth outcomes, rates of preventable hospitalizations, and treatment outcomes for certain health conditions, including not only those tied to episodes of LWV-TN Comments on TennCare Amendment 42 care but also outcomes clinically related to any benefit adjustments or formulary changes made under the block grant funding scheme. ➢ Insufficient provision for oversight of program administration and clinical decisionmaking related to alterations in benefits and formularies Amendment 42 requests broad flexibility and relief from CMS regulations but specifies no mechanisms for clinical or administrative oversight by entities other than the state TennCare bureaucracy or the state legislature. This amounts to a lack of state accountability for the use of taxpayer dollars allotted to TennCare. It is vital not only to retain a significant level of federal oversight but also for the Amendment to specify a transparent process for independent and expedited clinical review of cases involving enrollees whose medical needs might require exemption from formulary limitations or benefit adjustments triggered under a block grant framework. There also needs to an objective independent process for reviewing how such appeals for exemption are resolved. One projected source of additional "savings" discussed in the Amendment would be achieved by limiting the current Medicaid formulary to the least expensive medications in a given therapeutic class. The prospect of new formulary restrictions has raised a great deal of public concern, particularly for those with chronic conditions. There is considerable genetic variation in the ability to metabolize and tolerate medications, and the least expensive medications are not always the most cost-effective. Some individuals may even experience serious side effects from medications that are considered safe for the general population. For example, persons with latent long QT syndrome—a potentially fatal congenital cardiac condition which requires diagnosis through EKG and stress testing or genetic testing—are unable to tolerate medications that impact heart rate or conductivity in even subtle ways. Over 270 medications on most formularies are contraindicated for patients diagnosed with long QT syndrome, including generic antibiotics, antihistamines, antidepressants, antivirals, antacids, anticancer drugs and asthma medications. Though not a common condition, this condition is not rare. Applying current estimates of prevalence, there are 500-600 current TennCare recipients with this condition. How would their medication needs be handled with a limited formulary? Other chronic conditions require progressively staged treatment through a changing medication regimen because the effectiveness of initial drugs is known to wane over time. Would each step up to a more effective but more expensive medication require a lengthy appeal process? The proposed focus on cost of medications rather than case-by-case cost-effectiveness is clinically short-sighted and questionable. CMS would be abrogating its mandate to use waivers to innovate in ways that do no harm if this waiver were approved without the specification of mechanisms for the provision of broad clinical oversight and expedited appeals. We are concerned that the costs of these necessary patient protections have not been sufficiently weighed in the preparation of this proposal. LWV-TN Comments on TennCare Amendment 42 The League of Women Voters of Tennessee recommends that TennCare articulate how it would convene a non-partisan oversight commission to assure that any decisions to alter the TennCare program are based not only on cost, but also clinical effectiveness for affected populations. In addition, we urge TennCare to allow CMS to retain oversight over benefit changes with potential clinical impact and on overall evaluation of this program. ➢ Failure to address the state’s health coverage gap, which is contributing to high rates of uncompensated care and hospital closures in rural areas Expanding TennCare eligibility to include uninsured low-income adults is more in keeping with the intent of the Medicaid statute than Amendment 42, The federal Medicaid program was designed to help eligible Americans with limited resources obtain health coverage for medically necessary care. The TennCare block grant waiver is more narrowly focused on leveraging billions of dollars in federal funding without strict accountability to taxpayers for how it is used or for whom. Tennesseans are already tired of paying the freight for more generous Medicaid programs in other states; now we are also being asked to tolerate higher risks for an even less generous program. The block grant waiver proposal does not expand TennCare eligibility for any uninsured low-income adults. LWVTN has long supported programs designed to decrease the number of individuals lacking health insurance in Tennessee and to increase access to preventive, primary, and acute health care that is cost-effective for all Tennesseans. To that end, our members have been persistent advocates for the expansion of Medicaid to include uninsured, nondisabled adults without dependent children, with income up to 138 percent of the federal poverty level ($17,236 annual income limit in 2019 for one household member in 48 contiguous states including Tennessee and the District of Columbia). The League of Women Voters of Tennessee strongly recommends amending the TennCare waiver to expand eligibility for these uninsured low-income adults. Expanding TennCare eligibility would: • Reduce adverse selection and the average per capita cost of TennCare beneficiaries, improving program viability over the long term. • Reduce the state’s uninsured rate and alleviate the burden of uncompensated care which has contributed to more hospital closures in Tennessee than in any other state. • Improve the health and productivity of approximately 300,000 uninsured Tennesseans who currently delay or forego health care because their incomes are too high for Medicaid but too low to qualify for tax credits to buy marketplace coverage or to afford comprehensive commercial insurance. • Contribute to the reduction of health care costs in Tennessee over the long term through improvements in individual and public health. • Significantly increase the federal Medicaid match rate for TennCare enrollees with income up to 138% FPL—from 65.87% in 2019 to 90%. If TennCare eligibility were expanded, the state would be responsible for only 10% of expenditures for the expansion population instead of 35.13%, amounting to a projected influx of an estimated 26 billion dollars in federal payments over the next decade.4 The expansion alternative would not preclude efforts to develop robust wrap-around services for TennCare recipients with chronic health conditions, including mental illness and substance use disorders, but would in fact make these services more accessible to low income Tennesseans at points in their lives when intervention can have more lasting impact (e.g., before pregnancy, before incarceration, before addiction). The LWV-TN stands ready to assist our state and our TennCare program with constructive and innovative ways to improve the health of all Tennesseans. Amendment 42 is not the way to achieve these goals, and in fact puts at risks gains that have been made or could be made through efforts to expand rather than restrict the TennCare program. In its current form we can not support Amendment 42 and will urge CMS to reject it. References: 1. Division of TennCare TennCare II Demonstration Project No. 11-W-00151/4 Amendment 42 DRAFT. May 24, 2019. Available at https://www.tn.gov/content/dam/tn/tenncare/documents2/TennCareAmendment42.pdf 2. Center on Budget and Policy Priorities. Tennessee Block Grant Proposal Threatens Care for Medicaid Beneficiaries. September 25, 2019. Available at https://www.cbpp.org/research/health/tennesseeblock-grant-proposal-threatens-care-for-medicaid-beneficiaries 3. The Sycamore Institute. Breaking Down TennCare’s Block Grant Proposal. September 19, 2019. Available at https://www.sycamoreinstitutetn.org/breaking-down-tenncares-block-grant-proposal/ 4. The Commonwealth Fund. What a Medicaid Block Grant Would Mean for Tennessee: An Update. September 25, 2019. Available at https://www.commonwealthfund.org/blog/2019/what-medicaidblock-grant-would-mean-tennessee-update 5. United Health Foundation. America’s Health Rankings. Annual Report 2018. Available at https://www.americashealthrankings.org/explore/annual/measure/Overall/state/TN Jonathan Reeve From: Sent: To: Subject: Attachments: Martie Lafferty Friday, October 18, 2019 5:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] CREEC Comments on Proposed Amendment 42--Tennessee Medicaid Block Grant 2019-10-18 CREEC Comments on TN Proposed Medicaid Block Grant.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please accept the attached comments on Proposed Amendment 42.    Martie Lafferty  (she/her)   Director of the Accessibility Project   Civil Rights Education and Enforcement Center    525 Royal Parkway, #293063    Nashville, TN 37229   (615) 913‐5099   mlafferty@creeclaw.org  www.creeclaw.org       1 525 Royal Parkway No. 293063 Nashville, TN 37229 615.913.5099 www.creeclaw.org Martie Lafferty mlafferty@creeclaw.org October 18, 2019 Via email to public.notice.tenncare@tn.gov Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 RE: Comment on Proposed Amendment 42 –Tennessee Medicaid Block Grant Dear Director Roberts: The Civil Rights Education and Enforcement Center (CREEC) is a nonprofit membership organization whose goal is to ensure that everyone can fully and independently participate in our nation’s civic life without discrimination based on race, gender, disability, religion, national origin, age, sexual orientation, or gender identity. Our scope is nationwide and we have offices in Colorado, California, and Tennessee. CREEC’s Accessibility Project works to ensure that people with disabilities have equal access and opportunities. We submit these comments on Amendment 42 due to our concerns that converting Tennessee’s federal Medicaid funding to a block grant would have a substantial negative impact on Tennesseans with disabilities. The proposed block grant would result in at least $2 billion being cut from the $12 billion TennCare program. Such a substantial cut cannot possibly result in maintenance of even the current, often inadequate, level of services to TennCare recipients. In fact, the proposal specifically allows Tennessee to reduce the amount of care a recipient receives including the following: 1. Eliminating or restricting services like physical therapy, hospice, EPSDT for children, and medication, as well as arbitrarily limiting who receives these services; 2. Reducing core health care services such as hospital care and emergency services; 3. Allowing Medicaid managed care plans to restrict access to needed care; and Gabe Roberts, Director October 18, 2019 Page 2 4. Excluding coverage of key prescription drugs. All of these proposed changes will jeopardize the health of TennCare recipients with disabilities, including medically fragile children eligible for the newly developed Katie Beckett waiver program. This block grant proposal would also have a negative impact on long-term supports and services including CHOICES and ECF CHOICES. This would result in decreased opportunities for people with disabilities to live as independently as possible in home and community settings. Even now, there are approximately 7,000 people with intellectual and developmental disabilities waiting for enrollment into ECF CHOICES. This “referral list” will only continue to grow if Tennessee’s Medicaid program becomes a block grant. Proposed Amendment 42 also asks for decreased federal oversight through removal of requirements for TennCare to reapply or be re-evaluated. Such oversight is essential to assure the quality of TennCare services and TennCare’s compliance with federal requirements. Removing this oversight could eliminate essential federal health standards and safeguards for not only TennCare but also its managed care organizations (MCOs). Given the negative impact that proposed Amendment 42 would have on people with disabilities, CREEC strongly opposes this proposed amendment. Sincerely, CIVIL RIGHTS EDUCATION AND ENFORCEMENT CENTER Martie Lafferty Director of the Accessibility Project Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Mary Linden Friday, October 18, 2019 1:05 PM PUBLICE NOTICE TENNCARE Mary C. Shelton [EXTERNAL] TAADAS comments on Amendment 42 TAADAS Medicaid Block Grant - Amendment 42 Comments 10-18-19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please note the attached copy of TAADAS’ comments on Tennessee’s Block Grant Proposal ‐ Amendment 42.  Thank you  for your consideration.     Mary-Linden Salter, LCSW  Executive Director  Tennessee Association of Alcohol, Drug & other Addiction Services  Airport Executive Plaza  1321 Murfreesboro Pike Suite 155  Nashville, TN 37217  Office: 615‐780‐5901, ex 118    Note new phone extension  Cell: 615‐579‐8808  https://smile.amazon.com/         1 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: gvmt flks Wednesday, September 25, 2019 5:17 PM PUBLICE NOTICE TENNCARE senator dickerson; rep mitchell [EXTERNAL] Amendent 42 to TennCare TennCare II amend 42.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   please find the attached comments related to the public notice period  thank you  maureen      ‐‐   maureen organ  5041 grady lane  whites creek tn 37189  1 Comments regarding Amendment 42 to TennCare II Demonstration 9/25/2019 I am a retired nurse who worked both in Public Health and health care management. I am all too familiar with the historic compensation and system issues in the TennCare program in areas of eligibility, enrollment and disenrollment, the fee schedule and claims processing. This block grant waiver angers me. It should be called TennCareLess. It is nearly entirely focused on spending less money vs helping more people. It seems that our legislature and governor fail to comprehend the most basic principle of their responsibility for the public health. Everyone that is able to receive appropriate health care services improves the health of all. Conversely, everyone who is excluded is a risk to everyone’s health. It is a fact that it is nearly impossible to obtain care without some form of third-party payment but we have a significant part of our population that has none. Our focus should be on expanding TennCare coverage, which is currently paid more than 65% by the federal government, not on spending less money. The basic premise of this block grant is arrogant and unsubstantiated-that Tennessee can do it better without interference from the federal government. There is not a shred of evidence in the proposal of achieved improvements in health outcomes, only financial success. The Medicaid program was established in 1965 and has been fine tuned for those 54 years to be the best it can be and also control cost. The mandates of the program are based on this rich heritage. It has also become a huge and awkward bureaucracy with many legacy rules and procedures that are probably unnecessary. Operational reforms would be better addressed through a national action of governors vs our one state listing its litany of complaints. Our TennCare program has an historic reputation for inefficiency, arbitrary and damaging disenrollment and lack of assistance to resolve issues. In general, the provider community chooses to participate in the program thru a sense of duty and mission and not because it works for them financially or administratively. One of the most serious problems faced by people currently covered under the plan is to find a provider that will actually take care of them. The idea that the creation of an entirely new system from scratch would be efficient and cost effective and provide improved health outcomes is a lovely idea. At best would be a decade long process of essentially reinventing the wheel. Developing outcome successful interventions is better left to the health care professions. There are portions of the plan that I find especially egregious. 1. The single drug per indication formulary displays the lack of informed professional involvement in the plan’s development. We are individual humans and one size does not fit all. Denying new therapies, especially in rare diseases, would be a death sentence to some. 2. The amount of attention paid to the issue of fraud is totally disproportionate to the volume of about 100 instances. Again, to deny TennCare to an otherwise eligible person due to fraud represents a potential danger to public health. 3. The statement of Senator Bailey, one of the legislative sponsors, that Medicaid should be a temporary measure for adults evidences his lack of comprehension or of empathy for those who become permanently disabled thru illness of injury and is very concerning. Thank you for considering these comments. Maureen C Organ, RN, BSN, MPA 5041 Grady Lane; Whites Creek, TN 37189 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Lee, Aiden J Friday, October 18, 2019 10:00 AM PUBLICE NOTICE TENNCARE Buntin, Melinda J. Beeuwkes; Alexander, Suzanne [EXTERNAL] TennCare II Demonstration Amendment 42 TennCare Amend 42 - public comment.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Roberts,     Please find attached the comment letter regarding Amendment 42 to the TennCare II Demonstration submitted on  behalf of Dr. Melinda Buntin of Vanderbilt’s Department of Health Policy.    Best,  ‐‐   Aiden Lee  Health Policy Analyst I   Department of Health Policy  Vanderbilt University Medical Center   Phone: 615‐875‐9934  aiden.j.lee@vumc.org   1 Department of Health Policy October 17, 2019 Mr. Gabe Roberts Director, Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Mr. Roberts, Thank you for the opportunity to comment on TennCare’s proposed waiver amendment for the implementation of a block grant (Amendment 42). I am writing in response to the call for public comments from the perspective of a health policy researcher with an interest in improving the health of Tennesseans. I understand that Amendment 42 is the result of legislation passed by the Tennessee General Assembly requiring the Governor and administrators of TennCare to request a block grant from the federal Centers for Medicare and Medicaid Services (CMS) within 180 days, and that the legislation specified both the general form of the block grant and that Tennessee should request maximum flexibility in implementing it. I am concerned that, in asking for these flexibilities, TennCare has not been specific enough about how they would be used and to what end. Specifically, I would hate to see Tennessee miss this opportunity to lay out some important goals and how the flexibilities and additional funding/shared savings requested under the proposal would be deployed. The following are examples of important, concrete, and actionable goals and measures that would be meaningful to all Tennesseans. • • • Reduce infant mortality in the state of Tennessee from 7 per 1,000 births to at most the national level of 5.8 by increasing outreach to women at risk of a pre-term birth, enhancing programs to help pregnant women and parents to stop smoking, reducing administrative barriers to long-acting reversable contraception, and offering free cribs, car seats, home visits from nurses, and other evidence-based services to all at-risk families. Reduce maternal mortality from over 35 maternal deaths per 100,000 live births to at most the national level of 30 by extending the eligibility of all pregnant women covered by TennCare for at least a full year following delivery and fully funding the implementation of the recommendations of the TDH’s Maternal Mortality Review Committee. This committee found that 85% of these maternal deaths are potentially preventable, and a full third of these are related to unmet needs resulting from mental health conditions and substance abuse. Increase the funding available under the “Katie Beckett” waiver to ensure that families with severely disabled children do not remain on a waiting list for enrollment or services. VANDERBILT UNIVERSITY 2525 West End Avenue www.vumc.org/health-policy/ Suite 1200 tel 615.322.1324 Nashville, TN 37203 These types of goals and messages can, of course, be part of TennCare’s plans regardless of the outcomes of the block grant waiver negotiations with the federal government. Given that the proposal states that there is no intention of reducing benefits or tightening eligibility requirements, however, and given TennCare’s history of large-scale planned disenrollment, providing concrete examples of extensions of eligibility and services is particularly meaningful at this juncture. In addition, those of us in the research community cannot fail to note that continued research and evaluation is an important part of any waiver, and especially one that would bring unprecedented changes as this waiver amendment would. If TennCare hopes to be a national model in terms of innovation and financing then it is critical to rigorously evaluate changes and demonstrate what works. If such evaluations are not conducted, other states will not be able to argue for or replicate any successes. In addition, the complexity of health care and the many changes occurring within the health care industry at the same time mean that sophisticated data and methods are needed to separate the true “signal” of a successful (or disappointing) program from the “noise” of other health system developments. We look forward to continued discussion with the Division of TennCare on these matters. Sincerely, Melinda B. Buntin, Ph.D. Mike Curb Professor of Health Policy Chair, Department of Health Policy Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Andrew Hebert Friday, October 18, 2019 3:43 PM PUBLICE NOTICE TENNCARE Michael Boyd [EXTERNAL] Gilead Comments on Notice of Change in TennCare II Demonstration: Amendment 42 Gilead Tenncare II Demonstration Waiver Amendment 42 Comments 2019 10 18 - Signed.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Gabe Roberts,     Please find attached Gilead’s comments on the TennCare II Demonstration Waiver Amendment 42 request. Please let us  know if have any questions or concerns.     Best,     Andrew     __________________________ ANDREW HEBERT Government Affairs & Policy Gilead Sciences 333 Lakeside Drive Foster City, CA 94404 andrew.hebert@gilead.com 650.235.2473    1 Jonathan Reeve From: Sent: To: Subject: Attachments: Mike Dvorak Monday, October 14, 2019 3:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant Comments Block.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Roberts,  On Behalf of the Tennessee Dental Association, please see our attached comments regarding the TennCare Block  Grant proposal.     If you have any questions, please feel free to contact us at the number below.  Thank you very much.   Michael S. Dvorak, MSL  Executive Director  Registered Lobbyist      Tennessee Dental Association  660 Bakers Bridge Ave., Suite 300  Franklin, TN 37067  msd@tenndental.org  PH: 615‐628‐0208    www.tndentalassociation.com              1                                                                                          Comments on Tennessee Block Grant Proposal                 October 14, 2019    The Tennessee Dental Association (TDA) believes that Medicaid plays an essential role in the state’s oral  health safety net. We believe that dentistry and oral health, as they relate to the importance of “whole‐ body health,” receive serious consideration during this process and be recognized equally with medical.  The TDA opposes Medicaid block grant proposals if adequate funding and safeguards are not in place to  ensure access to comprehensive oral health services. Although a Tennessee Medicaid official has said  that the savings from the block grant could be used to provide limited dental care for some people, the  TDA believes that there is not enough information on this proposal, including what type of dental care  would be included and who would gain access to those services. Without more information and without  an assurance that these dental services will definitely be added, we cannot support the block grant.   The TDA also has concerns about the funding and structure of the block grant. The proposal would cap  Tennessee’s federal Medicaid funding for children, low‐income parents, and people with disabilities,  based on the state’s projected costs of serving those populations without the waiver. This structure  could incentivize the state to cut services to these vulnerable populations. In 2017, dental expenditures  in Tennessee were 1.9% of the total Medicaid expenditure, and the state could cut those dental costs in  order to save on overall Medicaid costs. The demand for such cuts could further increase if Tennessee  faces higher than anticipated per‐person costs due to factors such as natural disasters, a public health  crisis like the opioid epidemic, expensive new prescription drugs and technologies, or an economic  recession.   The state also proposes that it have the flexibility to make changes, without federal approval, to the  amount, duration, and scope of covered benefits. Waiving this federal protection and allowing the state  to limit benefits without a transparent oversight process could threaten access to oral health services  provided to children under the Medicaid Essential Health Benefits (EHBs).   It is also important to note that fees for current providers of TennCare have not seen a significant raise  for the better part of a decade and we would not want those patients compromised in any fashion in  receiving the coverage they desperately need.  Additionally, the TDA is concerned about the proposal to exempt Tennessee from the federal  government’s regulations for managed care plans. The protections offered by these regulations on  issues such as network adequacy for managed care plans are critical to ensuring that Medicaid  beneficiaries have access to dental care.   Sincerely,            Terryl Propper, DDS, MS      President, Tennessee Dental Association        Michael S. Dvorak, MSL  Executive Director, Tennessee Dental Association                                         660 BAKERS BRIDGE AVE SUITE 300 FRANKLIN, TENNESSEE 37067  PHONE (615) 628‐0208 FAX (615) 628‐0214  Jonathan Reeve From: Sent: To: Subject: Attachments: Gordon Bonnyman Wednesday, October 16, 2019 9:26 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on TennCare Amendment 42 2019-10-16 TN Justice Ctr. Comments on Amend.42.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please see comments attached.     Thank you.     Gordon Bonnyman  Tennessee Justice Center  211 7th Avenue, N, Ste. 100  Nashville, TN 37219  Phone: 615‐255‐0331  Direct: 615‐846‐4708  Cell: 615‐496‐9895  gbonnyman@tnjustice.org    1 Jonathan Reeve From: Sent: To: Subject: Attachments: Mindy Cameron Friday, October 18, 2019 10:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Proposed changes to TennCare Public comment re TennCare changes final.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you for the opportunity to submit comments to proposed Amendment 42 to the TennCare II Demonstration.     Sincerely,     Mindy Cameron   Advocacy Director  Little Hercules Foundation  www.littleherculesfoundation.org                1 Little Hercules Foundation 5522 Avery Road, Dublin, Ohio 43016 614.389.0026 littleherculesfoundation.org October 18, 2019 Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: Public Comment to Proposed TennCare Changes Dear Mr. Roberts, We are a patient advocacy group working with patients and families affected by Duchenne muscular dystrophy and other rare genetic conditions. We are writing in response to the call for public comments regarding Tennessee’s efforts to transition to Medicaid block grant funding, as well as the state’s proposed changes to prescription drug coverage under Medicaid. We are certain that you are aware of the emergence of gene and cell therapies to treat genetic diseases, so we do want to point out that many rare disease patients on Medicaid in Tennessee will need access to these important therapies. We sincerely hope that these therapies have been accounted for in your plans to move toward a block grant funding model. The Little Hercules Foundation would be happy to meet with you so that you can better understand Duchenne and other similar rare disorders and the impact these gene and cell therapies will have on the entire spectrum of life with these conditions. Patients with genetic neuromuscular conditions like Duchenne also need access to a wide range of medications, durable medical equipment, home health care, care coordination, and home and vehicle modifications. As advocates for patients in Tennessee who are affected by these conditions, we want to emphasize the importance of ensuring that these needs will be accounted for if the state moves to block grant funding. In regard to the state’s plan to adopt a commercial-style closed prescription drug formulary, we believe this could have negative effects on the health of Medicaid beneficiaries in Tennessee. As you know, different patients respond differently to different drugs and having only one option per therapeutic drug class would seriously harm the health of patients in any disease state. Duchenne patients, for example, respond differently to corticosteroids and they need to be able to take the option best suited for their long-term health. Our patients who have been on one corticosteroid for years should not be forced to switch because of a state mandate, as these decisions are best left up to the patient and their treating physician. Additionally, if a patient experiences negative side effects from one medication, it must be possible for that patient to try an alternative. SERVING THE DUCHENNE MUSCULAR DYSTROPHY COMMUNITY THROUGH ADVOCACY, AWARENESS, FAMILY ASSISTANCE AND RESEARCH FUNDING Finally, we want to call attention to treatment options that are approved through the FDA’s accelerated approval pathway. The state’s proposal calls for flexibility to exclude these new drugs from the formulary, thus enabling the state to deny access to Medicaid beneficiaries that could benefit from them. The entire premise of accelerated approval is to offer patients potentially life-saving treatments as quickly as possible if the FDA determines that the treatments are reasonably likely to provide benefit in disease states of high unmet need. To deny these potentially life-saving treatments to Medicaid patients, many of whom are children, is most definitely not in the interest of public health. As you are aware, CMS issued a notice to states in June of last year to reiterate that drugs approved under the AA pathway must be covered by state Medicaid programs if they are able to satisfy the definition of covered outpatient drug, if they are used for a medically-accepted indication, and if the manufacturer has an applicable signed Medicaid national drug rebate agreement for participation in the MDRP. We invite your response to our concerns and look forward to working with you to make sure the needs of Duchenne and other rare disease patients are adequately accounted for as Tennessee seeks to transition the way it implements Medicaid to its state beneficiaries. Sincerely, Kelly Maynard President, Little Hercules Foundation Mindy Cameron Advocacy Director, Little Hercules Foundation Page 2 Jonathan Reeve From: Sent: To: Subject: Attachments: Misty Adams Friday, October 18, 2019 12:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] We appreciate the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4). TennCare II Demonstration Amendment 42Comment Letter.pdf     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐        Misty   1 October 18, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts: F.R.I.E.N.D.S. (Friends Reaching, Inspiring, and Educating Neighbors about Down Syndrome) appreciates the opportunity to submit comments on the TennCare II Demonstration Amendment 42 (Project No. 11W-00151/4). Our vision is to enhance the quality of life for people with Down syndrome by promoting our mission to provide members group support and to promote community understanding about people affected by Down syndrome. F.R.I.E.N.D.S. supports over 100 individuals with Down syndrome (Ds) from birth to adulthood. Our organization provides resources, valuable programs, and events for families and caregivers affected by Ds. In our 19 years since inception, we have become an important part of the TriCities and surrounding areas, both internal and external to the special needs population. We strive to provide for our families a stable base of support and a strong community that will last a lifetime. The purpose of the Medicaid program is to provide healthcare coverage for low-income individuals and families. F.R.I.E.N.D.S. is committed to ensuring that TennCare provides quality and affordable healthcare coverage. Unfortunately, this waiver proposal to convert the funding structure of the TennCare program to a block grant will jeopardize beneficiaries’ access to care. F.R.I.E.N.D.S. opposes Tennessee’s proposal and offers the following comments. Block Grant Structure F.R.I.E.N.D.S. opposes Tennessee’s proposal to change the financing structure for its Medicaid program to a block grant. F.R.I.E.N.D.S. fears that the state will cut coverage for certain treatments completely or impose additional barriers to important services, making it more difficult for patients to access the care that they need. Additionally, Tennessee may choose to cut payments to providers to help keep spending under the new block grant. As the gap between the block grant and actual costs of care increases over time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost-sharing for patients will only increase. These cuts are unacceptable. This structure will not protect either the state or beneficiaries from financial risk. The per capita adjustments to the block grant will not be sufficient if an unexpected event, such as a public health crisis, increases per person healthcare costs. For example, there are many ground-breaking treatments in development for patients with serious and chronic illnesses. If an expensive but highly effective treatment became available, Tennessee’s spending could rise, putting the state’s budget at risk and creating an incentive for the state to impose additional barriers for that treatment. Tennessee’s proposal would include vulnerable eligibility groups such as children and people with disabilities in the block grant. We have serious concerns about how this will impact their care. Individuals with Down syndrome face a variety of health concerns, such as congenital heart defects, hearing and vision loss, respiratory problems, obstructed digestive tracts, childhood leukemia, and other health conditions. Establishing high-risk pools, defining subpopulations and/or setting fixed amounts could be complex, arbitrary, and detrimental to people with Down syndrome, many of whom would not fit neatly into one category of complexity or subpopulation. According to the National Institutes of Health, at least one-half of all people with Down syndrome also have co-occurring conditions that contribute to their medical complexity. For example, approximately half of all children with Down syndrome are born with congenital heart disease. A person with Down syndrome may also be defined as a person with a disability, a person with cancer, and a person with Autism, and a person with Alzheimer’s disease. Proposals that provide for block grants and per capita payment caps, including those that fund high-risk pools, must account for the many combinations of complicated health care needs that people with Down syndrome will face throughout their lifespan. Additionally, under this proposal, current and future administrations would not need to get approval to make changes to benefits and services, putting these patients’ care at grave risk. • • • • Creating longer waiting lists for services. Cutting home and community-based services and supports that make it possible to live independently and work in the community. Reducing other critical services such as personal care, mental health, prescription drugs, and rehabilitative services. Shifting the financial burden for health care, community supports and long-term services to families and individuals, many of whom lack financial means to provide these important services. Changing TennCare to a block grant through the 1115 waiver process is illegal. The Secretary of Health and Human Services is not permitted to waive Sections 1903 and 1905, where the financing structure of the Medicaid program is located, through these types of waivers, as multiple experts have noted.1,2 Such a change would require congressional authority, yet Congress has repeatedly declined to pass legislation on this issue, most recently during the debate over repealing and replacing the Affordable Care Act in 2017. Prescription Drug Access F.R.I.E.N.D.S. opposes the proposal to create a closed formulary with as few as one drug per class and exclude prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated approval process. Limiting access to medications will be detrimental to over 400,000 individuals with Down syndrome. Prescription drugs have different indications, different mechanisms of action, and different side effects, depending on the person’s diagnosis and comorbidities. Restricting TennCare’s drug benefits to a closed formulary would limit the ability of providers to make the best medical decisions for the care of their patients, effectively taking the clinical care decisions away from the doctor and patient and giving them to the state. Allowing TennCare to exclude prescription drugs approved through FDA’s accelerated processes will harm patients by restricting access to novel and lifesaving therapies. The waiver proposal does not include an appeals process for patients to access prescription drugs that are no longer covered. TennCare patients include very low-income pregnant women, the elderly, children and the blind and disabled. These individuals rely on Medicaid to provide treatment and may need access to a medication no longer covered under the new restrictions. Without an appeals process to access denied medications, these patients could experience worse health outcomes and even death. State Flexibilities F.R.I.E.N.D.S. opposes a number of proposals in the waiver application considered under the broad moniker of “state flexibilities.” Tennessee is asking to be exempt from federal standards and requirements for its managed care program, including the Managed Care Rule. This important safeguard ensures Medicaid Managed Care Organizations (MCOs) have to meet certain requirements related to patient care. For example, the managed care rule sets standards related to adequate networks, so patients can actually see the appropriate providers and receive the care they need. The managed care rule requires MCOs to comply with standards of time and distance to measure this network adequacy, helping patients access both primary care providers and specialists they need. Tennessee is asking to change the “amount, duration, and scope” of benefits, which could allow the state to put caps on services or only cover critical services for certain individuals. The Medicaid population, by definition is a vulnerable population, allowing Tennessee to change the “amount, duration, and scope” of benefits could impact negatively impact patient care and outcomes. Finally, the state would no longer need to get approval to make changes to benefits and services in the future and would like to make this demonstration permanent, removing important opportunities for the public to provide feedback on the how the program is working for key stakeholders before any policies are implemented or continued. It is especially important that beneficiaries impacted by the demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint venture between Tennessee and CMS. Both entities, as well as the people it serves, should have a voice in how the program is administered. Due to advances in medical technology, individuals with Down syndrome are living longer than ever before. Today, as many as 80 percent of adults with Down syndrome reach the age of 60, and many live even longer. This necessitates access to affordable health care and long-term services and supports throughout an increased lifespan. Efforts to reform the Medicaid program should seek to address the gaps and barriers to health care that prevent individuals with Down syndrome from experience a high quality of life as they transition from childhood to working adult to senior citizen. This includes access to wellness and prevention services, health and health disparities research, patient-centered care models, and increased professional training for health care providers. Fiscal Sustainability If Tennessee is truly concerned about the fiscal sustainability of its Medicaid program, the state could submit a state plan amendment to fully expand Medicaid to 138 percent of the federal poverty level and receive a 90 percent match from the federal government for all expenses for the adult expansion population. This policy would both benefit the state financially and extend access to care to more lowincome individuals in need of coverage, a core objective of the Medicaid program. Tennessee has also failed to provide a complete budget neutrality estimate with details of the projected changes in spending with the waiver and any impact on coverage. The federal rules at 431.408 pertaining to state public comment process require at (a)(1)(i)(C) that a state include an estimate of the expected increase or decrease in annual enrollment and expenditures if applicable. The intent of this section of the regulations is to allow the public to comment on a Section 1115 proposal with adequate information to assess its impact. Given that this waiver represents a fundamental change to Tennessee’s demonstration, the state should include these projections and their impact on budget neutrality provisions. The core objective of the Medicaid program is to furnish healthcare to low-income and needy populations. This waiver does not further that goal and F.R.I.E.N.D.S. opposes the proposal. Thank you for the opportunity to submit comments. Sincerely, Misty Adams, President F.R.I.E.N.D.S. 965 Meadowbrook Rd., Afton, TN 37616 865-898-7828 mistyadams2@gmail.com 1 Joan Alker. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown University Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/ pending-cms-guidance-on-medicaid-block-grants-executive-overreach-strikes-again/. 2 https://theincidentaleconomist.com/wordpress/tennessee-wants-to-block-grant-medicaid-is-that-legal/ Jonathan Reeve From: Sent: To: Subject: Attachments: Moore, Daveisha Friday, October 18, 2019 12:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Comments Komen Comments_TN Medicaid Block Grant.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you so much for the opportunity to submit public comments regarding Tennessee’s Medicaid Block Grant  proposal. Please see Susan G. Komen’s comments attached.        Daveisha Moore, MPH Regional Manager, State Policy & Advocacy SE Susan G. Komen® P: 972-855-4309 C: 5005 LBJ Freeway, Suite 526 Dallas, TX 75244 1-877-GO-KOMEN komen.org   1               October 18, 2019    Mr. Gabe Roberts  Director of TennCare  Deputy Commissioner, State of Tennessee   Department of Finance and Administration  310 Great Circle Road  Nashville, TN 37243    Re: TennCare II Demonstration Amendment 42 (Project No. 11‐W‐00151/4)    Dear Director Roberts:     Susan G. Komen appreciates the opportunity to submit comments on the TennCare II Demonstration  Amendment 42 (Project No. 11‐W‐00151/4). Komen is the world’s largest breast cancer organization,  funding more breast cancer research than any other nonprofit outside of the federal government while  providing real‐time help to those facing the disease. Since its founding in 1982, Komen has funded more  than $956 million in research and provided more than $2.1 billion in funding to screening, education,  treatment and psychosocial support programs serving millions of people in more than 30 countries  worldwide.     Komen has set a Bold Goal to reduce the current number of breast cancer deaths by 50 percent in the  U.S. by 2026. In order to achieve our Bold Goal, we believe that scientific progress and community  services must be complemented by sound public policy and advocacy.  Through government action,  broad, systemic, and lasting change can be made in the fight against breast cancer.  We work closely  with local health care providers and those impacted by breast cancer in communities across our country,  affording us the unique opportunity to share with you their collective concerns on this demonstration.     The purpose of the Medicaid program is to provide healthcare coverage for low‐income individuals and  families. Komen is committed to ensuring that TennCare provides quality and affordable healthcare  coverage. Unfortunately, this waiver proposal to convert the funding structure of the TennCare program  to a block grant will jeopardize beneficiaries’ access to care. Komen opposes Tennessee’s proposal and  offers the following comments.     Block Grant Structure   Komen opposes Tennessee’s proposal to change the financing structure for its Medicaid program to a  block grant. Komen fears that the state will cut coverage for certain treatments completely or impose  additional barriers to important services, making it more difficult for patients to access the care that  they need. Additionally, Tennessee may choose to cut payments to providers to help keep spending  under the new block grant. As the gap between the block grant and actual costs of care increases over  time, the pressure on Tennessee to limit enrollment, reduce benefits or increase cost‐sharing for  patients will only increase. These cuts are unacceptable.                 This structure will not protect either the state or beneficiaries from financial risk. The per capita  adjustments to the block grant will not be sufficient if an unexpected event, such as a public health  crisis, increases per person healthcare costs. For example, there are many ground‐breaking treatments  in development for patients with breast cancer. If an expensive but highly effective treatment became  available, Tennessee’s spending could rise, putting the state’s budget at risk and creating an incentive  for the state to impose additional barriers for that treatment. Additionally, under this proposal, current  and future administrations would not need to get approval to make changes to benefits and services,  putting these patients’ care at grave risk.     Changing TennCare to a block grant through the 1115 waiver process is illegal. The Secretary of Health  and Human Services is not permitted to waive Sections 1903 and 1905, where the financing structure of  the Medicaid program is located, through these types of waivers, as multiple experts have noted.i,ii Such  a change would require congressional authority, yet Congress has repeatedly declined to pass legislation  on this issue, most recently during the debate over repealing and replacing the Affordable Care Act in  2017.    Prescription Drug Access   Komen opposes the proposal to create a closed formulary with as few as one drug per class and exclude  prescription drugs approved through the Food and Drug Administration’s (FDA) accelerated approval  process. Limiting access to medications will be detrimental to breast cancer patients.     Prescription drugs have different indications, different mechanisms of action, and different side effects,  depending on the person’s breast cancer diagnosis and comorbidities. Restricting TennCare’s drug  benefits to a closed formulary would limit the ability of providers to make the best medical decisions for  the care of their patients, effectively taking the clinical care decisions away from the doctor and patient  and giving them to the state. Restricting or delaying medications for those living with advanced stage  breast cancer or other terminal illnesses could cost them their life. Allowing TennCare to exclude  prescription drugs approved through FDA’s accelerated processes will harm patients by restricting  access to novel and lifesaving therapies.     The waiver proposal does not include an appeals process for patients to access prescription drugs that  are no longer covered. TennCare patients include very low‐income breast cancer patients, pregnant  women, the elderly, children and the blind and disabled. These individuals rely on Medicaid to provide  treatment and may need access to a medication no longer covered under the new restrictions. Without  an appeals process to access denied medications, these patients could experience worse health  outcomes and even death.     State Flexibilities   Komen opposes a number of proposals in the waiver application considered under the broad moniker of  “state flexibilities.”     Tennessee is asking to be exempt from federal standards and requirements for its managed care  program, including the Managed Care Rule. This important safeguard ensures Medicaid Managed Care  Organizations (MCOs) have to meet certain requirements related to patient care. For example, the  managed care rule sets standards related to adequate networks, so patients can actually see the  appropriate providers and receive the care they need. The managed care rule requires MCOs to comply   2         with standards of time and distance to measure this network adequacy, helping patients access both  primary care providers and specialists they need.    Tennessee is asking to change the “amount, duration, and scope” of benefits, which could allow the  state to put caps on services or only cover critical services for certain individuals. The Medicaid  population, by definition is a vulnerable population, allowing Tennessee to change the “amount,  duration, and scope” of benefits could impact negatively impact patient care and outcomes. Breast  cancer, like many other cancers and disease, can require varying combinations of treatment specifically  for those with the most aggressive types of cancer. Limiting the “amount, duration, or scope” to these  patients could be life threatening.     Finally, the state would no longer need to get approval to make changes to benefits and services in the  future and would like to make this demonstration permanent, removing important opportunities for the  public to provide feedback on the how the program is working for key stakeholders before any policies  are implemented or continued. It is especially important that beneficiaries impacted by the  demonstration waiver have the ability to provide feedback to the state and CMS. TennCare is a joint  venture between Tennessee and CMS. Both entities, as well as the people it serves, should have a voice  in how the program is administered.     Fiscal Sustainability   If Tennessee is truly concerned about the fiscal sustainability of its Medicaid program, the state could  submit a state plan amendment to fully expand Medicaid to 138 percent of the federal poverty level and  receive a 90 percent match from the federal government for all expenses for the adult expansion  population. This policy would both benefit the state financially and extend access to care to more low‐ income individuals in need of coverage, a core objective of the Medicaid program.    Tennessee has also failed to provide a complete budget neutrality estimate with details of the projected  changes in spending with the waiver and any impact on coverage. The federal rules at 431.408  pertaining to state public comment process require at (a)(1)(i)(C) that a state include an estimate of the  expected increase or decrease in annual enrollment and expenditures if applicable. The intent of this  section of the regulations is to allow the public to comment on a Section 1115 proposal with adequate  information to assess its impact. Given that this waiver represents a fundamental change to Tennessee’s  demonstration, the state should include these projections and their impact on budget neutrality  provisions.     The core objective of the Medicaid program is to furnish healthcare to low‐income, vulnerable  populations. This waiver does not further that goal and Komen opposes the proposal. Thank you for the  opportunity to submit comments.     Sincerely,         Molly Guthrie  Director, Public Policy & Advocacy  Susan G. Komen  3        i  Joan Alker. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown  University Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/  pending‐cms‐guidance‐on‐medicaid‐block‐grants‐executive‐overreach‐strikes‐again/.  ii  https://theincidentaleconomist.com/wordpress/tennessee‐wants‐to‐block‐grant‐medicaid‐is‐that‐legal/  4 Jonathan Reeve From: Sent: To: Subject: Attachments: Alexanderia Honeycutt Gambrell Wednesday, October 16, 2019 10:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant comments OSP Comment - TN Medicaid Block Grant.pdf *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. *** Please find attached comments regarding the Block grant. Alexanderia Honeycutt Gambrell Honeycutt Strategies 305 Kent Road Nashville, TN 37214 615-495-8091 1 COMMENTS ON TENNESSEE MEDICAID BLOCK GRANT TENNCARE II DEMONSTRATION PROJECT NO. 11-W-00151/4 – AMENDMENT 42 DIVISION OF TENNCARE October 16, 2019 Sam Adolphsen Senior Research Fellow Opportunity Solutions Project (OSP) writes in support of Tenncare II Demonstration Project NO. 11-W-00151/4 Amendment 42, the Medicaid Block Grant waiver request. The primary objective of this proposal is to bring more flexibility to the state of Tennessee in how they administer their own Medicaid program, and to provide the state with the tools and authorities necessary to implement efficiencies and cost controls within the program to preserve resources for the truly needy and taxpayers of Tennessee. OSP offers our support for this proposal and encourages Tennessee to tailor the request to maximize state flexibility and ensure that both the current and future federal administrations are bound to recognize Tennessee’s authority to direct the policies and practices within its Medicaid program. The proposal would give Tennessee Medicaid much-needed program control While Medicaid is a federal and state partnership program, the federal government has significant control over the policies within the Medicaid program. This creates inefficiency as the state agency closest to the members the program serves looks for tools and methods to best administer the program. The proposed block grant can help remedy that inefficiency, giving Tennessee more direct control--and incentive through shared savings—to rein in costs. Tennessee’s Medicaid program has grown rapidly in recent years, and the state needs more options to respond to the growing demand and financial strain within the current program. In 2000, Tennessee’s Medicaid program spent a total of $4.54 billion annually, with a state share of $1.56 billion.1 By 2018, that number had increased dramatically to $11.66 billion in total spending and $4.45 billion in state funds annually.2 This growth means that Tennessee spends an ever-increasing amount of state funding on the Medicaid program, which has the effect of crowding out spending on other programs or priorities. State spending on Medicaid now represents 32.2 percent of all state spending in Tennessee. 3 This is more than any other category of Tennessee spending, including K-12 education. This growth is in large part due to the increase in able-bodied adults on Medicaid. Nationally, the number of able-bodied adults on Medicaid has quadrupled, from 7 million in 2000 to 28 million in 2018.4 Although Tennessee has wisely resisted the expansion of Medicaid to all ablebodied adults under 138 percent of federal poverty level, the program still covers 249,000 such adults today.5 The proposal will preserve resources for the truly needy and taxpayers The proposal will help Tennessee refocus the program on the truly needy it was meant for. As a result of increased caseloads and costs, Tennessee has waitlists for some individuals with disabilities who are waiting for home-based care that can help keep them out of more expensive institutions and allow them to stay in their own homes. More than 7,000 intellectually and developmentally disabled individuals are waiting for these services.6 Through the cost controls that Tennessee will be able to put in place as a result of the block grant, as well as the potential shared savings Tennessee will receive when they create OPPORTUNITY SOLUTIONS PROJECT 2 efficiency in the program, there is a great opportunity to redirect state funds back to the truly needy individuals with disabilities Medicaid is meant to serve. Under the current Medicaid funding mechanisms, Tennessee receives more federal funding only when they spend more. This creates a poor incentive structure, rewarding not only increased enrollment, but also inefficient spending that has no direct link to health outcomes. Under the proposed block grant, Tennessee will correct those incentives, helping the state to focus on effective spending that achieves positive health outcomes efficiently. When successful, Tennessee can use the savings to invest further in the health of their citizens, with significant potential savings to Tennessee taxpayers. The proposal will help reduce fraud One of the important specific pieces mentioned as an example in the proposal is illustrative of the positive benefits that Tennessee can derive from the block grant. Tennessee correctly highlights Medicaid program fraud as a major issue that the state will tackle using new authorities granted under the proposal. Medicaid fraud is a significant and growing problem, and states are not currently allowed by the federal government to use basic checks and tools to stop the fraud. More than 10 percent of Medicaid spending is improper, with more than $60 billion in annual fraudulent spending in the program nationwide.7 More than half of this improper spending is the result of eligibility related errors, most of which are committed by recipients.8 One of the primary gaps is that those individuals who commit fraud intentionally are allowed back onto the program. This proposal will allow Tennessee to freeze out fraudsters, at least for a period of time. Tennessee mentions 12 months as a proposed lockout period, which OSP supports. However, OSP would suggest that Tennessee extend this beyond the criminal-level fraud mentioned as an example in the proposal, and also include those who commit fraud, but are only sanctioned on an administrative level through an Intentional Program Violation or similar administrative procedure, and others who fail to report changes in circumstances as required by law. This will ensure anyone trying to gain access inappropriately to Medicaid when they are not truly eligible will be barred from the program at least temporarily. Under this proposal, Tennessee will also be able to pursue other anti-fraud measures, including those that other states have already had approved by CMS, for example a lockout period for those recipients who fail to properly report changes to their income, like Kentucky requested and received approval for in their 1115 waiver.9 Conclusion Opportunity Solutions Project is pleased to offer our support for Tennessee’s block grant proposal. It is an innovative proposal that will preserve Tennessee resources for the truly needy and taxpayers, and protect the program from fraud and abuse. OPPORTUNITY SOLUTIONS PROJECT 3 Endnotes 1 National Association of State Budget Officers, “2000 State Expenditure Report,” (2001), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b7500fca152d64c2/UploadedImages/SER%20Archive/NASBO%20StExpRep%202000.pdf. 2 National Association of State Budget Officers, “2018 State Expenditure Report,” (2018), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b7500fca152d64c2/UploadedImages/SER%20Archive/2018_State_Expenditure_Report_S.pdf. 3 Ibid. 4 Nic Horton, Jonathan Ingram, “The future of Medicaid reform: Empowering individuals through work,” Foundation for Government Accountability (2017), https://thefga.org/wpcontent/uploads/2017/11/The-Future-of-Medicaid-Reform-Empowering-Individuals-Through-Work.pdf. 5 MACStates, “Medicaid full-year equivalent enrollment by state and eligibility group,” Medicaid and CHIP Payment and Access Commission (2018), https://www.macpac.gov/wpcontent/uploads/2015/11/EXHIBIT-15.-Medicaid-Full-Year-Equivalent-Enrollment-by-State-andEligibility-Group-1.pdf. 6 State Health Facts, “Waiting list enrollment for Medicaid section 1915(c) home and communitybased services,” Kaiser Family Foundation (2019), https://www.kff.org/report-section/key-questionsabout-medicaid-home-and-community-based-services-waiver-waiting-lists-appendix-tables/ 7 Victoria Eardley, Jonathan Ingram, “How the Trump administration can crack down on Medicaid fraud,” Foundation for Government Accountability (2018), https://thefga.org/wpcontent/uploads/2018/12/Eligibility-12.13.18.pdf. 8 Ibid. 9 Adam Meier, “Kentucky HEALTH 1115 demonstration modification request,” Kentucky Health (2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Waivers/1115/downloads/ky/ky-health-pa2.pdf. OPPORTUNITY SOLUTIONS PROJECT 4 Jonathan Reeve From: Sent: To: Subject: Attachments: Pam Wright Friday, October 18, 2019 2:14 PM Jonathan Reeve [EXTERNAL] Amendment 42 - Public Hearing in Jackson Public Hearing Statement 11 3 2019.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Hi Mr. Reeve, I offered comments at the public hearing in Jackson. You asked me to email them and they are attached.    Thank you,    Pam F Wright  1 PUBLIC HEARING, NOVEMBER 3, 2019 My name is Pam Ford Wright. I am a resident of Madison County. I am an attorney specializing in Elder Law which means that I often represent individuals who need access to health care. That need may arise from a major medical crisis, a life-long medical condition or functional impairment or frailty brought on by aging or dementia. I am opposed to Amendment 42 for the following reasons: WRONG GOAL Tennessee typically ranks in the bottom 10 states – across many health indicators -- on national health rankings. I do not understand why our state leadership seeks to create a health program that does NOT set goals for maintaining or IMPROVING the health status of Tennesseans. The Governor has set one concrete and measurable goal for this plan: to reduce the current program by TWO BILLION DOLLARS. The reductions will made to the “core medical services for TennCare’s core population.” There are no stated, concrete, measurable goals for achieving health care standards or improvements. As designed, savings from a health care program can be used by the state for anything, diverting needed funds from an already strapped system. REMOVAL OF FEDERAL STANDARDS AND INDEPENDENT OVERSIGHT The plan removes the federal standards for insurance operations by the MCOs, the companies that handle all of the health care and provider systems. This opens the door to fraud and abuse by sketchy insurance plans with their fake, inadequate networks and junk payment systems. This puts providers and consumers at grave risk. TennCare has an unfortunate history of being taken to the cleaners by fraudsters. We already know the costs and the damage that will cause. Why invite them back? There is no provision for independent assessment of the changes that will arise from the amendment. There is no trigger for intervention in the event health outcomes or systems become dangerously compromised (as has happened in the past). There is no independent oversight to protect the interests of our vulnerable health systems and vulnerable consumers. And, without standards, what could intervention do anyway? SHIFTING OF MAJOR HEALTH RISKS AND COSTS TO CONSUMERS The cost-sharing burdens imposed under Amendment 42 will cause TennCare to become just another factor contributing to unsustainable medical costs for cashstrapped individuals and families. Tennessee already leads the nation in medical bankruptcies. Why do we seek to worsen that situation? Under this proposal, the state will eliminate some optional State Plan benefits. Most Tennesseans – and their legislators – don’t even know which of the state plan benefits are optional. For example, pharmaceutical coverage is an optional benefit. The state proposes a radical reduction in that benefit. Other optional benefits include home health services, physical therapy, hospice care and respiratory treatment. Removing coverage of necessary medical services will cause consumers to go without. AARP recently reported that, in 2017, 34% of Tennessee residents stopped taking medication as prescribed due to cost. REMOVAL OF CRITICAL CONSUMER PROTECTIONS The state seeks to operate a managed care program that does not comply with the requirements of the federal Medicaid regulations at 42 CFR Part 438. That section offers significant consumer protections, such as the guarantee of enrollee rights. It protects providers who advocate for the interests of their patients. It sets limits to the forms of MCO marketing. It protects consumers from having to pay bills that arise when there are payment disputes or failures between the MCOs and their providers. It gives the consumers the right to appeal a denial of service. Removing section 438 protections is extremely harmful to TennCare enrollees and providers. UNLAWFUL The Center for Medicare and Medicaid Services does not have the authority to authorize a block grant. Pursuing this course of action will inevitably place Tennessee in a long and costly legal battle. This will be yet another expensive burden for Tennesseans to bear. For all of these reasons, I am opposed to Amendment 42. I urge state leadership to forego an untested, and mean-spirited, experiment to save money. Rather, focus on strategies that have been proven to improve health outcomes. I support expanding Medicaid to serve working individuals with incomes that are below the federal povertylevel. There is proof that Medicaid expansion is successful in rural areas and in states with the same issues we face. It can work here. Finally, I thank the state for setting additional public hearings in Memphis and Chattanooga. I join with other commentators in requesting that the state offer additional and ongoing public comment and hearing opportunities as the proposed amendment moves through the review process with CMS. Jonathan Reeve From: Sent: To: Subject: Attachments: Peter Witzler via ActionNetwork.org Monday, October 7, 2019 11:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Gabe Roberts, Director Division of TennCare, Oppose TN Medicaid Block Grant 392b5368ec70408d1a56316778a2b499581f47b2_signatures_201910070359.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Gabe Roberts, Director Division of TennCare, 0 people have signed a petition on Action Network telling you to Oppose TN Medicaid Block Grant. Here is the petition they signed: You can view each petition signer and the comments they left you in the attached PDF. Thank you, Peter Witzler   Sent via Action Network, a free online toolset anyone can use to organize. Click here to sign up and get started building an email list and creating online actions today.   Action Network is an open platform that empowers individuals and groups to organize for progressive causes. We encourage responsible activism, and do not support using the platform to take unlawful or other improper action. We do not control or endorse the conduct of users and make no representations of any kind about them. You can unsubscribe or update your email address or change your name and address by changing your subscription preferences here.       1 Gabe Roberts, Director Division of TennCare, 0 people have signed a petition on Action Network telling you to Oppose TN Medicaid Block Grant. Here is the petition they signed: You can view each petition signer and the comments they left you below. Thank you, Peter Witzler Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Rachel Klein Friday, October 18, 2019 1:50 PM PUBLICE NOTICE TENNCARE Carl Schmid; Stephanie Hengst [EXTERNAL] Comments on Amendment 42 to TennCare II The AIDS Institute TN 1115 Medicaid Waiver Comments Final.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please see attached comments regarding The AIDS Institute's concerns about key provisions of proposed Amendment 42  to the TennCare II Medicaid Section 1115 Demonstration Waiver. Do not hesitate to reach out if you have any  questions.     Rachel Klein Health Policy Manager  The AIDS Institute    1705 DeSales St NW, Suite 700 Washington, DC 20036  Office: 202-835-8373 Mobile: 202-815-2973 Fax: 202-835-8678     rklein@theaidsinstitute.org  www.theaidsinstitute.org  1 October 18, 2019 Gabe Roberts Director of TennCare Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: Comments on Tennessee Medicaid Section 1115 Waiver Request Dear Mr. Roberts: The AIDS Institute, a national, non‐partisan, non‐profit organization dedicated to supporting  and protecting health care access for people living with HIV/AIDS, hepatitis, and other chronic  and serious health conditions, is pleased to submit comments on the Tennessee request to  amend its Amendment 42 to its TennCare II Medicaid Section 1115 Demonstration. We are extremely concerned that if Tennessee moves forward with Amendment 42 to the  TennCare II Section 1115 Demonstration, TennCare beneficiaries living with and at risk of  HIV, hepatitis, and other serious and chronic conditions will not have access to the life‐ saving and curative health care they need to keep them healthy and alive. Section 1115  waivers are required to promote the objectives of the Medicaid program. However,  Tennessee’s proposal to block grant TennCare runs contrary to the purpose of the program,  which is to provide access to necessary health care for those who cannot otherwise afford it.  Despite the state’s claims, block‐granting the Medicaid program will ultimately financially  hamstring the state, forcing benefit and eligibility reductions that will jeopardize the health of  low‐income, chronically ill, and disabled Tennesseans. Moreover, the Tennessee waiver  request includes specific provisions, including a closed formulary, that will put access to  healthcare for people with serious chronic conditions at risk. We encourage Tennessee to  withdraw this waiver proposal, which as it stands violates current law and would undermine  the Medicaid program not only for Tennessee, but potentially throughout the country. Financing Concerns Although we are sympathetic to the concern that rising healthcare costs place strain on state  budgets, we disagree with the proposal to radically restructure the financing mechanism for  Program and Administrative Office 17 Davis Blvd., Suite 403, Tampa, FL 33606 Ph: 813-258-5929 National Policy Office 1705 DeSales St NW, Suite 700 Washington, DC 20036 Ph: 202-835-8373 www.theaidsinstitute.org  TennCare. Like all state Medicaid programs, TennCare is funded through a partnership  between the state and the federal government, with the government paying 65 percent of the  costs of the program. This unlimited matching from the federal government has allowed the  state to increase help to those most in need. TennCare, having operated via a Section 1115  Waiver since the mid‐1990s, is already one of the more streamlined programs in the country.  The proposed financing structure violates current Medicaid law. Section 1115 of the Social  Security Act allows the federal government to waive provisions in Section 1902 of the Act,  which defines eligibility, enrollment, benefits, beneficiary protections, and delivery system  requirements. The program’s financing structure is defined in Section 1903 of the Act, which is  not waivable via a Section 1115 waiver.   Additionally, The AIDS Institute is concerned that Tennessee’s request to cap the amount of  federal funding for TennCare would result in insufficient flexibility for the state to respond to  necessary increases in funding due to unforeseen public health crises causing a sudden  increase in medical needs or an influx of enrollment, as the current funding structure permits.  Although the proposal includes an adjustment for per capita enrollment increases, the only  inflation factor for per capita costs is related to Congressional Budget Office (CBO) projections.  For example, the Administration’s new End the HIV Epidemic Initiative could result in Medicaid  enrollment increases among adults living with HIV, as more people become aware of their  status and seek treatment due to increased HIV testing. These individuals may be likely to have  higher‐than‐average medical costs, even after adjusting for the cost of prescription drugs.  Likewise, the opioid crisis, which is sparking both HIV and HCV outbreaks across the nation,  and advances in medical technology are likely to increase costs in ways that are not included in  the state’s proposed financing methodology. If innovations in medical technology or other  delivery system innovations result in cost increases that the CBO does not anticipate, the state  will be “on the hook” for these expenses without federal financial participation, forcing the  state to either use scarce general fund resources to finance the program, or reduce  expenditures to fit within the limitations of the block grant.    Moreover, a per capita payment for individuals that is not based on actual healthcare  expenditures jeopardizes the fiscal integrity of the Medicaid program. Unlike the traditional  claims‐based Medicaid program, the state would receive federal reimbursement for enrollees  without any guarantee that these individuals are receiving care commensurate with said  reimbursement. Under the state’s proposal, Tennessee would not see any reduction in its  block grant amount if it spends less than projected. This financing system would incentivize  the state to reduce services rather than increase access to care.  Three key proposals within the waiver give life to this concern: 1) the request to limit the  prescription drug formulary to as little as one drug per class; 2) the request to exempt TennCare  from the federal Medicaid Managed Care Regulations; and 3) the request that further changes to  the benefit package and delivery system not be subject to federal oversight and approval.      2  Prescription Drug Formulary Waiver Request  Access to medications is central to the well‐being of all people living with HIV, who now can live a  relatively healthy, normal life if they have full access to the antiretroviral treatment prescribed to  them and take them on a daily basis for the rest of their life. Access to direct acting antivirals for  the treatment of hepatitis C now provides a cure to patients in as little as eight weeks for a once  deadly virus. Daily treatment is also available for people living with hepatitis B, who can also lead  a normal, healthy life if they have access to medications that they must take daily for the rest of  their life. Each of these viruses are infectious diseases that, in the interest of public health, must  be controlled. With the medications now available, we can actually end HIV and hepatitis as a  public health threat. In Tennessee, there are currently over 16,000 people living with HIV and estimates of 122,500  people living with hepatitis C (HCV). Overall, 19 percent of Tennesseans are covered by Medicaid.  Considering that Medicaid is now the largest payer for all people living with HIV who are in care  nationwide, many people in Tennessee living with HIV are reliant on Medicaid as their source of  healthcare coverage.  As part of the waiver request, the state is proposing to fundamentally and dramatically change  the coverage of prescription medications by creating a restricted prescription drug formulary.  This not only violates current Medicaid law, but would impose irreparable harm to beneficiaries.  The AIDS Institute urges Tennessee to withdraw this proposal. What Tennessee is requesting violates current Medicaid law. Currently, Section 1927 requires  states to cover all drugs of a pharmaceutical manufacturer that participates in the federal  Medicaid rebate program, while allowing them to use “permissible restrictions”. In exchange for  this requirement, states receive a minimum 23.1 percent rebate plus additional rebates when  manufacturers increase the price of their drug above inflation. States may receive supplemental  rebates by using a preferred drug list. In violation of this law, Tennessee is proposing to institute  a closed formulary with as little as one drug available per therapeutic class. Since this would be  in violation of current Medicaid law and is not a provision that can be waived, The AIDS Institute  urges Tennessee to withdraw this provision of the Waiver Request. Not only is what Tennessee is requesting through the 1115 Waiver Request illegal, it would also  be bad for beneficiaries, particularly those living with HIV, hepatitis and other serious and  chronic conditions. Treatment of many illnesses, including HIV and hepatitis, is tailored to each  patient based on the unique health conditions experienced by each patient. Providers must  prescribe the drugs that best meet their patients’ needs. Limiting the number of drugs available  to just one drug per class does not take into account important factors that must be weighed  when designing a patient‐specific treatment regimen. For example, some individuals may develop  side‐effects in response to a particular drug, while another person may need a certain therapy to  avoid a harmful interaction with a drug being taken for a different health condition. People living  with HIV and hepatitis frequently have co‐morbid conditions and are prescribed multiple  medications for their other health concerns that interact differently with their HIV and hepatitis  drugs. Furthermore, drug resistance can occur in people living with HIV and hepatitis, requiring    3  them to switch to another drug without interruption in order to maintain viral suppression or to  keep their condition in check. It is important that patients, especially those with chronic  conditions such as HIV and HCV, have access to a broad array of medications to manage their  health and avoid disease progression which can cause further complications for the individual,  increase the risk for the public’s health, and put additional burden on the healthcare system long‐ term.  Providers cannot be limited in prescribing the best drug to meet their individual patient’s medical  needs. Tennessee’s proposal would do exactly that, limit a provider’s ability to treat their  patients. For people living with HIV and hepatitis, if patients do not have access to their  medications, it can result in illness and death. Additionally, it would impede progress in  controlling infectious diseases, which would be contrary to what is best for the public health.  In another proposal that would circumvent current Medicaid law, Tennessee is proposing to  not cover certain medications that came to market through the FDA’s accelerated approval  pathway. First, this would be a violation of the law. Section 1927 does not allow states to pick  and choose what types of medications must be covered but requires coverage of all FDA  approved drugs of manufactures that participate in the rebate program. These drugs are FDA  approved. Secondly, these accelerated approval drugs still must meet FDA standards for approval  and are on the accelerated approval process in order to meet the needs of patients who have  rare or complicated diseases with few or no treatment options. In the interest of patient health,  The AIDS Institute urges Tennessee to withdraw this aspect of the waiver as well. Ability to Change Benefits Without Oversight  The proposal requests authority to add or eliminate coverage of optional benefits and the  amount, duration, and scope of all benefits without any oversight by the federal government.  Such a change would allow the state to stop covering important services such as prescription  drugs without informing the federal government, or to limit access to specialty care needed by  people with serious, chronic conditions. The state’s request to waive the comparability standard  would allow it to limit access to a certain service or set of benefits to only some people in a state.  But the Medicaid benefit package is designed to be comprehensive, because it is difficult to  predict what health care any particular individual may need in a given year, and people who rely  on Medicaid do not have sufficient income or savings to pay out‐of‐pocket for healthcare that is  not covered by the program. Patients may have comorbid conditions, complications from a  condition, or unanticipated acute healthcare needs that require a more comprehensive benefit  package.   Exemption from Medicaid Managed Care Regulations  Amendment 42 to the TennCare II Demonstration requests that TennCare be exempted from  complying with federal Medicaid Managed Care Regulations. Since almost all TennCare enrollees  are enrolled in managed care, such an exemption would put many people with serious, chronic  illnesses at risk of not getting the care they need. The federal rules governing Medicaid managed  care include rules related to network adequacy, beneficiary appeals of managed care plan    4  decisions, quality measurement standards, and managed care plans obligations regarding delivery  of services. These protections are particularly important for people living with serious chronic  health conditions such as HIV and hepatitis, who have complex medical care needs and often  require access to clinicians who have a certain expertise or set of services, and a broad  prescription drug formulary. Without these protections, people with complex needs in TennCare  could face significantly difficulty gaining access to the care they need.  We thank you for the opportunity to submit these comments. If you have any questions or  comments, please feel free to contact me at rklein@theaidsinstitute.org. Sincerely,  Rachel Klein  Health Policy Manager      5  Jonathan Reeve From: Sent: To: Subject: Attachments: Raven T Chism (rtchism) Friday, October 18, 2019 4:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment on Block Grant Letter to Comment on TN Medicaid Block Grant.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***       Raven T. Chism     Notes Editor Vol. 50 The University of Memphis Law Review   Research Assistant to Professor Donna Harkness   Policy Research Assistant to Professor Amy Campbell      Student Justice, Honor Council     J.D. Candidate, May 2020  The University of Memphis   Cecil C. Humphreys School of Law  rtchism@memphis.edu   901.859.9877      1 Mr. Gabe Roberts Director, Division of TennCare 310 Great Circle Road Nashville, TN 37243 October 14, 2019   To Mr. Gabe Roberts: I am writing this letter to address my concerns with the Tennessee Medicaid Block Grant Proposal. I oppose this proposal because  it is extremely ineffective in ensuring quality care and does not guarantee health insurance access to those who have the greatest medical and health care needs. Vulnerable populations such as the elderly, disabled, children, and pregnant women will be at a great disadvantage if the government decides to go through with enacting a block grant for the Medicaid program. Additionally, the proposal should be declined because it fails to provide the minimum consumer protections against the state. Placing a cap on health care entitlements will have negative effects on the community as it will further limit access and services to our most vulnerable populations. Tennessee is a very impoverished state. It is ranked 9th in nation for having the highest poverty rates and is 6th in the nation as one of the unhealthiest states. These two factors show that Medicaid is greatly needed, and many people here in this state are dependent on Medicaid funding. The Governor states that people who are already receiving coverage under Medicaid will not lose their coverage but there is no guarantee that they will also maintain the same amount of services as the government prioritizes cutting cost under the proposed block grant. Cutting cost by placing caps on this program will cause the thousands of low-income citizens to go without essential services. The block grant is flawed because it does not take into full consideration cost for necessary services that our most vulnerable populations use and does not address exactly where the federal funds and savings will go. Working as a student attorney in the Medical- Legal Partnership Clinic at the University of Memphis Cecil C. School of Law, I’ve witnessed many low-income patients who desperately need their health care services and benefits. Many of our patients are disabled children needing extensive care— sometimes up to 24 hours of care every day. Under the current system, eligible children can get many of the services and medication that they need without having to worry about cost. All eligible low-income parents with eligible sick children have one less thing to worry about under the current system and this feature should not be changed because everyone deserves access and quality health care. The governor has prided Tennessee on being cost-efficient and more responsible in its spending habits than other states when it comes to medical expenses. Governor Bill Lee stated, “[o]ver 10 years we’ve saved the federal government a significant amount of money because of the efficiencies that we’ve operated our plan under....” However, with Tennessee ranking among the top ten in unhealthiest states, it shows that the government’s plan in cutting cost is ineffective and has not been beneficial to the community’s health overall. According to the World Health Organization, the poor are “more vulnerable to chronic diseases because they have increased exposure to risk and decreased access to health services.” It is a fear that this block grant, which places high priority on cutting cost, will only decrease access. This can put many of our lowincome people at an even higher risk for chronic diseases if we eliminate access. Most importantly, the greatest issue is that this block grant eliminates the protections for consumers—specifically low-income and vulnerable populations. The current system is backed by the support and oversight of the federal government. If the state fails to provide and follow minimum standards under Medicaid, then the federal government will intervene. I believe this safeguard is an extremely important protection for low-income citizens. Tennessee has already failed to provide its citizen with more health care access by declining to expand Medicaid in 2015. Now approximately 675,000 individuals are uninsured and the number continues to rise as thousands of Tennesseans, mainly children, where recently dropped from TennCare for issues in paperwork. These issues demonstrate Tennessee’s lack of support for low-income working poor class and there is no guarantee that money for the block grant will be provided to expand coverage for this community of low-income people. The state’s lack of support for low-income citizens and primary focus to cut cost causes me to have a lack of trust that the government will actually prioritize medically underserved communities. There is already such a wide gap of health disparities and inequalities and the block grant will only widen the health inequalities and gaps in coverage that already exist. I highly recommend that the State of Tennessee decline this new proposal, and in the alternative consider Medicaid expansion for health care reform purposes. The state should decline the block grants as it further threatens access to health services in vulnerable populations and fails to provide consumer protections against the state who has already proven to value cutting cost over improving and saving lives. Best regards, Raven Chism Jonathan Reeve From: Sent: To: Subject: Attachments: Kelly, Rebecca B. - RBKelly Thursday, October 17, 2019 4:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] AARP TN Comments Final TN Comment letter for Medicaid Waiver - 101719-RBK.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   We appreciate the opportunity to provide public comment.  We also greatly appreciate the collaboration between AARP  TN and TennCare, and we look forward to continuing our working relationship.    Rebecca B. Kelly, MPA State Director / AARP Tennessee / 150 4th Ave. N., Suite 1350 / Nashville, TN 37219 Mobile – 615-828-7067 “Our greatest glory is not in never falling, but in rising every time we fall.”   1 October 17, 2019 Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Director Roberts: AARP, on behalf of its more than 640,000 Tennessee members, appreciates the opportunity to submit comments on the TennCare II Demonstration – Amendment 42 that seeks to convert the current federal share of its Medicaid funding for its core population to a block grant funding mechanism. We understand that the state is statutorily required to submit such a proposal given legislation passed by the Tennessee General Assembly in May 2019 (Public Chapter 481). AARP has a long history of advocating for quality, access to care, and member protections in the TennCare program and the healthcare system as a whole. While we appreciate TennCare’s thoughtful efforts to craft this proposed hybrid amendment, including the indexing of funding for inflation and enrollment growth, AARP nevertheless cannot support block grant funding mechanisms for the Medicaid program. We understand it is the state’s position that this amendment will not reduce benefits or enrollment; however, we are greatly concerned that with limited federal funds the most vulnerable low-income and disabled populations could be impacted with a loss of access to health and long-term care. Although the Tennessee proposal maintains some elements of traditional Medicaid by carving out certain needy populations from the block grant, such as the dual eligible population, AARP is deeply concerned that the proposed funding structure and waiver of certain federal protections and regulations will negatively impact the needs of the most vulnerable Tennesseans, especially in the TennCare CHOICES program. We hope that the state will consider these concerns as it contemplates other comments and how to proceed with this proposal. Funding Structure The block grant financing model proposed could potentially put the coverage of certain TennCare members at risk. Although the waiver amendment, if approved, would commit the state to a maintenance of effort requirement, the details on the source of this funding are not outlined, nor is there a clearly stated protection against supplanting existing state expenditures. The proposal outlines the state’s request for flexibility to spend “shared savings” dollars on items and services not otherwise covered under TennCare, or not otherwise eligible for federal match. AARP appreciates TennCare’s desire to invest in “health, not just health care,” as an approach to improve health outcomes for the TennCare population. We are, however, deeply concerned about the lack of clarity on what types of items and services would be offered to the TennCare population, and we would like to see clear criteria outlining how those funds could be spent. Flexibilities and Member Protections AARP Tennessee is concerned that in the state’s drive to secure flexibilities and administrative efficiencies, the proposal would eliminate important protections and oversight mechanisms that are crucial for TennCare members and required by law. In particular, the state seeks to allow “elimination of optional State Plan benefits” without CMS approval; to allow “changes in the amount, duration, and scope of State Plan benefits that do not affect the overall sufficiency of the benefit” also without CMS approval; and to eliminate federal managed care standards used to protect consumers and ensure managed care organizations deliver the services they have agreed to provide. This proposal also seeks to eliminate the state’s obligation to notify the public and to obtain stakeholder input as it moves to make changes to the program and seeks the authority to change program elements without demonstrating that the changes are consistent with federal law. The public notice and comment period is critical as it can help to inform the state of the impact of a proposed change, including its impact on Tennesseans in the program. Impact on TennCare CHOICES Another of our key concerns is the lack of specificity around how this proposal will intersect and potentially negatively impact TennCare CHOICES, the state’s integrated Medicaid managed long-term services and supports (LTSS) program instituted in 2010. Since the program’s inception, AARP has been a strong supporter of CHOICES, a program that provides home and community-based services (HCBS) as an alternative to nursing home care. AARP’s 2017 Long Term Care Scorecard reflects that progress that has been made in the last few years, and we would not want to see anything that could change that momentum. Thank you for the opportunity to provide our thoughts and concerns with the latest TennCare Demonstration Amendment 42 proposal. If you have any questions, please do not hesitate to contact me at rbkelly@aarp.org or 615-726-5100. Sincerely, Rebecca Kelly State Director Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Nicole G. Braccio Friday, October 18, 2019 3:13 PM PUBLICE NOTICE TENNCARE Rebecca A. Kirch [EXTERNAL] NPAF Comments to TennCare II Demonstration Amendment 42 (Project No. 11W-00151/4) NPAF Submission - Amendment 42 to TennCare II Demonstration.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts,    National Patient Advocate Foundation (NPAF) appreciates the opportunity to submit comments to Amendment 42.  Please do not hesitate to reach out to me if NPAF can provide further details or assistance.     Sincerely,  Nicole    Nicole Braccio, PharmD Policy Director  202‐516‐5212 •nicole.braccio@npaf.org      The information transmitted in this message (including file attachments) is covered by the Electronic Communications  Privacy Act, 18 U.S.C. 2510‐2521, is confidential and is intended solely for the use of the individual or entity to which it is  addressed. If you are not the intended recipient or the person responsible for delivering this information to the intended  recipient, be advised that you have received this information in error and that any use, dissemination, forwarding,  printing, or copying of this information is strictly prohibited. If you have received this information in error, please  immediately notify the sender and delete this information.   1 October 18, 2019 Gabe Roberts Director of TennCare Deputy Commissioner, State of Tennessee Department of Finance and Administration 310 Great Circle Road Nashville, TN 37243 Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) Dear Director Roberts, National Patient Advocate Foundation (NPAF) appreciates the opportunity to comment on Amendment 42 to the TennCare II Demonstration. NPAF supports policies that sustain and expand Medicaid to equitably and reliably meet the health care needs of low-income adults and children. We are concerned that the proposed block grant financing model would significantly jeopardize access to care for the most vulnerable patients and families in Tennessee leading to negative health consequences and further financial distress. NPAF represents the voices of millions of adults, children and families coping with serious and chronic illnesses as the advocacy affiliate of Patient Advocate Foundation (PAF). PAF provides direct case management, financial support, and educational services to tens of thousands of primarily low-income patients and caregivers nationwide each year who are experiencing distressing financial, employment, insurance coverage, or household material hardships because of their health conditions. Over the past ten years, PAF has served as an important safety net to nearly 6,000 patients and families in Tennessee. Overall, we oppose Amendment 42 which would alter the financing structure of TennCare to a block grant and create unprecedented discretion for states to reduce benefits, waive beneficiary protections and modify key program elements such as enrollment and service delivery. The various components of Amendment 42 constitute a radical change that would set a harmful precedent for other states to propose similar 1115 waivers to the Centers for Medicare and Medicaid Services (CMS). We echo the concerns of the broader patient community that CMS does not have authority under Section 1115 to permit Tennessee’s reimagined Medicaid financing model nor would the federal government match actual state Medicaid spending under this proposal. Importantly, the fiscal note of the proposal’s authorizing legislation, HB 1280 – SB 1428,1 does not evaluate or address impact on beneficiaries and therefore should be determined before the state moves forward with its waiver submission. Our PAF case managers have indicated that the impact to beneficiaries would be severe, causing confusion about covered benefits and services and incite fear of losing coverage altogether. A block 1 Tennessee General Assembly Fiscal Review Committee. Fiscal Note HB 1280 – SB 1428. February 25, 2019. Available at: http://www.capitol.tn.gov/Bills/111/Fiscal/HB1280.pdf 1 grant financing structure would put pressure on Tennessee to cut coverage for costly treatments. Moreover, Amendment 42 could lead to overly burdensome access barriers in the form of prohibitive utilization management practices and increased cost-sharing for beneficiaries. Specifically, NPAF strongly opposes the proposal to create a closed formulary with as few as one drug per class and exclude drugs approved by the Food and Drug Administration (FDA) under the accelerated approval process. A closed formulary would impede the delivery of timely and effective personalized treatment of patients’ conditions. Prescribed treatments should be the result of shared-decision making between patients and their health care team based on medical evidence and conversations they’ve had about what best meets the patient’s particular needs and circumstances. Additionally, waiving federal Medicaid managed care safeguards, which affects all of Tennessee’s Medicaid beneficiaries, could lead to greater network adequacy issues and denial of services for parents and children in the program. Our PAF case managers make clear that challenges with transportation and tradeoffs between health and cost of living expenses contribute to financial distress. Narrow provider networks and fewer covered benefits will only compound these challenges. Low-income patients and families coping with serious, chronic illness are already exposed to distressing circumstances and rely on Medicaid as a lifeline to meet their health care needs. Creating uncertainties about coverage would only exacerbate the emotional and financial distress already confronting lowincome pregnant women, parents, the elderly, children and the disabled. We understand that Tennessee is under significant pressure to reduce Medicaid spending and has taken steps to use 1115 waivers to implement changes that reign in health care costs. While fiscal sustainability is important, it cannot disrupt the wellbeing and health of patients and their families. Instead, Tennessee could improve access to care for more low-income individuals and benefit financially by submitting a state plan amendment to fully expand Medicaid to 138 percent of the federal poverty level, receiving a 90 percent match from the federal government. NPAF urges that TennCare protect patients from losing their health care coverage and instead pursue efforts that sustain equitable access to quality health coverage for the people it serves including parents and caregivers of seriously ill adults and children, people with disabilities and the elderly. Thank you for the opportunity to provide feedback on Amendment 42 to the TennCare II demonstration. Respectfully submitted, Rebecca A. Kirch EVP Health Care Quality and Value 2 SUPPORTING DOCUMENTATION ATTACHED 3 TENNESSEE GENERAL ASSEMBLY FISCAL REVIEW COMMITTEE FISCAL NOTE HB 1280 – SB 1428 February 25, 2019 SUMMARY OF BILL: Directs the Governor, acting through the Commissioner of the Department of Finance and Administration to submit a waiver amendment to the existing TennCare II waiver, or to submit a new waiver, in order to provide medical assistance to the TennCare II waiver population by means of a block grant in accordance with the provisions of this act no later than 120 days after the effective date of this act to the federal Centers for Medicare and Medicaid Services (CMS). The block grant authorized by this section must convert the federal share of all medical assistance funding for this state into an allotment that is tailored to meet the needs of this state and that is indexed for inflation and population growth. ESTIMATED FISCAL IMPACT: Increase State Expenditures – Not Significant Other Fiscal Impact - If approved by the federal government, the level of federal funding that would be approved for the Medicaid program is unknown. The current federal funding level for FY18-19 is approximately $7,544,537,000. Assumptions:  The Division of TennCare will not incur a significant increase in expenditures to submit the waiver amendment to the federal Centers for Medicare and Medicaid Services (CMS).  Should CMS approve the waiver amendment, it is unknown what restrictions will be placed on the amount of federal funding, what mandates will be placed on services or individuals served, what state funds will be required, and what will happen to current enrollees. IMPACT TO COMMERCE: Other Commerce Impact – Due to a number of unknown factors, an impact to commerce or jobs in Tennessee cannot be determined. HB 1280 – SB 1428 Assumption:  It is unknown what impact an altered benefit structure will have on capitation and payment rates and covered services to the managed care organizations and various health care providers. Due to these unknowns, an impact to commerce and jobs in Tennessee cannot be determined. CERTIFICATION: The information contained herein is true and correct to the best of my knowledge. Krista Lee Carsner, Executive Director /jem 2 HB 1280 – SB 1428 Jonathan Reeve From: Sent: To: Subject: Attachments: Mathews, Ella Thursday, October 3, 2019 3:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments on behalf of Rep. Jim Cooper (TN-5) Public Comment onTennCare Amendmemt 42 - Rep. Cooper.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Hello,     Attached is Congressman Jim Cooper’s public comment regarding Amendment 42.    Please let me know if there is a preferred format for the comments and I can resubmit.     Thanks,  Ella    Ella Mathews   Legislative Assistant  Rep. Jim Cooper (TN‐05)  1536 Longworth HOB  Washington, DC 20515  (202) 225‐4311    1 Testimony of Rep. Jim Cooper on TennCare II Demonstration, Amendment 42 Oct. 1, 2019 “History may not repeat itself, but it often rhymes.” – attributed to Mark Twain Let’s be completely honest. Tennessee is one of the unhealthiest states in America and we lead the nation in per capita hospital closings. Both of these tragedies are partly the result of our refusal to expand Medicaid. And this waiver request not only doesn’t help, it moves us backward. This radical, Trump-inspired plan would treat Tennessee like a guinea pig. Don’t take my word regarding our bad health. Ask Tennessee’s Department of Public Health, Nashville’s non-partisan Sycamore Institute or Sen. Bill Frist’s Health & Well-Being Index. Here are some of their examples: Although the outlook is better and better for Americans with cancer, not for us living in Tennessee. Cancer deaths are falling nationwide, but Tennesseans’ continue to climb. How about Tennessee children? They are more likely to die here than if you’re child in 40 other states. What if you are one of the two million Americans who suffer opioid abuse? There’s hope if you live in a state that expanded Medicaid where access to treatment centers have led to fewer overdoses. But in Tennessee, more of our people are overdosing. And what about the health of mothers in Tennessee? Of all of the maternal deaths in 2017, 85% were preventable. Think about that – many of these mothers might still be alive if Tennessee had only treated them better by expanding Medicaid. How can we explain our state government’s complicity in all this bad news? And Nashville dares call itself America’s health care capital! Now Tennessee is applying for its 42nd Amendment to its federal waiver in 25 years so that we can experiment again on our children, poor people and rural hospitals. The waiver application calls for refinancing “core medical services to its core population.” Shockingly, the waiver request barely mentions the health of Tennesseans because it’s such a low priority. Don’t forget that, since 2010, we have been offered almost a billion dollars a year in health assistance by the federal government. Perhaps if it had been offered by the Gates Foundation, we would have accepted it. Since 2010, we have made the cruel decision to reject federal money for ideological reasons. Never has our state turned down so much money, and we wouldn’t think of doing so for other causes. Only the medical needs of our most vulnerable are scorned. History: The Public TennCare Reform Efforts For the last twenty-five years, Tennessee Medicaid has been operating on a series of socalled Section 1115 waivers. In 1994, the legislature passed a page-and-a-half bill asking Gov. Ned McWherter to handle the problem of fitting medical care for the low income and disabled into tight state budgets. The legislature’s motivation was primarily financial, not medical. They were not trying to improve public health but to reduce state spending. Tennessee received its waiver from the Clinton Administration (McWherter was favorite of President Clinton), and TennCare was born in 1994. Tennessee’s big idea was managed care, forcing hundreds of thousands of poor Tennesseans into managed care plans because it might save lots of money. Of course, the legislature would never have dared force regular citizens or state employees into such plans. Reimbursements to these Managed Care Organizations under TennCare were so low that no national managed care company wanted to do business in Tennessee. Nevertheless, the legislature bulldozed ahead, waiting six years before seriously studying reimbursement levels. As a result, the entire crop of home-grown TennCare MCOs failed while waiting to be fairly paid for their work, leaving the state’s Medicaid patients in the lurch. When Gov. Phil Bredesen was elected in 2002, he had the advantage of having been a managed care executive. He knew that reimbursement levels for Medicaid had to be high enough to attract qualified managed-care providers. His change in reimbursement meant that Tennessee market was attractive to companies like Amerigroup and United – companies with proven management systems. Despite Gov. Bredesen’s expertise, he had to correct previous structural problems in the original design of TennCare, which forced the removal of 170,000 Tennesseans from the rolls. The Affordable Care Act, when passed in 2010, was a national fix a number of features of our health care system. It wasn’t perfect, but I was proud to vote for it on behalf of the 750,000 people I represent in Middle Tennessee. Gone were the laws that allowed insurance companies to dump people as soon as they got sick; gone were sham insurance policies that provided no benefits; gone were the higher premium charges for women; gone were the policies that prevented people with previous medical conditions from ever getting health coverage. All Americans, including Tennesseans, have been beneficiaries of these changes in the law. But the ACA was also designed to get not only the poor, but the low-income, medical insurance. This reform works wherever it is allowed to work, but not in Tennessee. The federal government committed to pay for the additional costs to states, and most states – enticed by the prospect of a realigned health care marketplace that was heavily subsidized by the federal government – signed up. The near-poor citizens of 36 states are now under the coverage of care, but not Tennesseans. Here, we had the third largest increase in uninsured in the nation last year. One out of every 10 people in our state, about 675,000 people, remain without any 2 health insurance. Read the first chapter of T.R. Reid’s book, The Healing of America. It describes a young Tennessee woman in her 30s who needlessly died of lupus for lack of medical care. To his credit, after Gov. Bill Haslam was elected, he supported expanding TennCare in this newly aligned system, and it was made easier because ALL of our Tennessee hospitals and provider groups also supported the effort. His plan was called “Insure Tennessee”, and it was chock-full of conservative features such as co-pays and work requirements. Nevertheless, the state legislature soundly rejected the Governor’s initiative after his half-hearted sales attempt and so began nearly a decade of refusing to expand TennCare. Gov. Haslam’s failure left Tennesseans in the sad situation of paying federal taxes so that other states could take better care of their citizens than we do. Now, eight years later, Gov. Bill Lee has been handed another page-and-a-half bill (H.B. 1280) by the General Assembly asking Gov. Lee to handle the same problems that Gov. McWherter first faced a quarter-century ago: tight state budgets with little room for the medical needs of our citizens who need it most. Gov. Lee has the same response: more managed care. The Hidden History: Gaming “the Match” Tennessee governors have been very creative in grabbing federal dollars to shoulder their constitutional responsibilities in caring for the medical needs of Tennesseans. No matter how generous the federal government has been in assisting states with their constitutional responsibilities, states always want more money to do the work the Constitution left to them. Medicaid was created in 1965 to offer federal matching grants to state-run Medicaid programs. Prosperous states like Connecticut get a 50% match, or one federal dollar for every state dollar. Lower-income states like Tennessee get a much better deal, a 65% match rate. That means about two federal dollars for every Tennessee dollar. Critics of this uncapped matching formula know that it has drawbacks and benefits. Federal generosity has spurred endless medical care price increases. Any attempt to reduce medical spending looks punitive because of the “ratchet effect” of, in Tennessee’s case, losing three dollars for every cut of one state dollar. Nevertheless, federal generosity under this formula has allowed dramatic improvements in health outcomes nationwide. The two-for-one match rate is so favorable to Tennessee that it creates incentives for Tennessee to look literally everywhere for money to earn more matching funds. Some of these efforts look laughable in hindsight. Tennessee hospitals once volunteered to give large “charitable” contributions to state government, with the implicit understanding that they would quickly get all their money back and more. These were not charitable contributions at all, but self-serving investments. When the federal government tried to close this blatant loophole, state officials complained that they were being unfairly treated. 3 After the charitable loophole was closed, hospitals began volunteering to have their beds taxed. Anytime someone volunteers to be taxed, especially with high taxes, you should get suspicious. These “provider-specific” taxes of, say, $10,000 per bed paid for themselves almost immediately with federal grants of $20,000 per bed. Once again, the feds closed this loophole, but only after Tennessee had taught many other states how to game the match. The third generation of TennCare loopholes involved using inter-governmental funds to boost our lawful 65% match rate to higher levels of matching. The goal is to get as close to 100% federal funding for TennCare as possible. The irony is that all along the Affordable Care Act offered 90% to 100% federal funding for expanding Medicaid. Under the ACA (or “Obamacare”), Tennessee could easily have boosted its match rate without needless delays or loopholes. Today’s Amendment 42 waiver request is really a fourth-generation loophole to get federal government to pay for virtually all of TennCare. By allowing Tennessee to use the highly-theoretical “savings” of its TennCare program vs. so-called “budget neutrality,” Tennessee is really seeking federal approval to spend as few state dollars as possible on the entire Medicaid population. This proposal moves Tennessee backwards, not forwards. Once again, our state’s proposed TennCare reforms are almost entirely budget-driven, not peopledriven. The valid argument that the legislature should be concerned about our nation’s fiscal situation is belied by the fact that Tennessee has long been a national leader in increasing federal deficits by milking the federal funds with every trick in the book, even inventing new tricks, while paying little or no regard to the health of poor Tennesseans. Also, our state cannot be trusted to stick to commitments to ask for less federal money. Tennessee once pledged it would not ask for the “disproportionate share” or DSH aid. Of course, the state soon reversed its position. The TennCare II, Amendment 42 Demonstration Request I had hoped that Gov. Lee’s religious faith would give him more of a heart for the poor, especially as we anticipate his Day of Prayer and Fasting later this month. His waiver request does not reflect what most states view as their duty to the poor. Remember, at least 36 states are doing better far than Tennessee in helping their most vulnerable. My biggest issues with the Amendment 42 request are hidden in plain sight. 1. The main thing the Amendment 42 request says is, “This is not Obamacare.” I understand that our legislature feels that way, but that emotion costs us $1 billion a year. That is staggeringly wasteful and out-of-step with public opinion. Obamacare has never been more 4 popular than it is today. All insured Tennesseans are benefitting from the many insurance reforms that were key elements of Obamacare such as pre-existing condition coverage. Not expanding Medicaid is one thing; shrinking it is worse. The waiver request allows cutting the eligible population of 1.4 million Tennesseans on Medicaid if, as has already been happening in our state, there are problems re-registering beneficiaries. 2. The second thing the Amendment 42 proposal says is, “We want a block grant.” The words “block grant” are very popular with state legislators. Who doesn’t want free federal money with no strings attached? But remember that Medicaid ALREADY has many aspects of a block grant (although, to be sure, it is way too complicated and bureaucratic). Unlike Medicare – health care for people over 65 – which is federally funded and administered, Medicaid was always mainly federallyfunded but state-administered. States have always had wide discretion to design their own Medicaid programs, without any waivers. With waivers, there is even more flexibility. That’s why Medicaid benefits vary widely from state to state. After 41 waivers, Tennessee has enjoyed extra flexibility. Of course, federal oversight remains to guarantee a safety net for the poor so that states do not mistreat their disadvantaged citizens. Amendment 42 asks permission to rip holes in the TennCare safety net that was supposed to protect all Americans. Do poor Tennesseans really deserve less protection than citizens of other states? A strong case can also be made that it would be illegal under federal law for Section 1115 to waive Section 1903 of the Medicaid statute. Gov. Lee seemed to acknowledge the unlikelihood of CMS granting his entire waiver request. If this part of the waiver request proves illegal, then what? If Amendment 42 is not severable, then denying any of the request negates the entire plan. 3. The third major feature of Amendment 42 is “shared savings.” Producing any genuine savings in medical care is nearly miraculous, like finding a Holy Grail, because medical spending nationwide has increased 2.5% faster than inflation for four decades. Tennessee seems so confident of savings that the waiver request offers to be responsible for 100% of any cost overruns. Such overruns may be harder to prevent than the state anticipates, despite the state excluding several volatile TennCare programs from its waiver request. There are only two ways to reduce spending on medical care if, as Amendment 42 says, there are no reductions in eligibility or benefits: providers must cut their prices or they must reduce the intensity or availability of care. 5 Have you ever heard of any hospitals, doctors, or other providers voluntarily cutting retail prices or having a sale? I never have, and I am guessing they don’t want to start now. Is the TennCare Bureau about to hammer Tennessee providers with lower reimbursement levels? Do we want more hospital closures and more physicians refusing to see TennCare patients? That leaves rationing care as the only way to reduce TennCare spending. The state must rely on the “tender mercies” of its Managed Care Organizations to figure out how to spend less on our poor without hurting them. That is the most likely way that any savings can be found, namely denials of care by Amerigroup, United, and Blue Cross of Tennessee. These three insurance companies will be in charge of doing the dirty work while our legislature washes its hands of the problem. Amendment 42 is really return to Gov. McWherter’s old playbook, with the difference that true management of care barely existed in 1994; companies that claimed to do it were really managing costs, not care. Health plans today have learned how to manage care but they are already using all the legal techniques in Tennessee. Do we really want to unleash them to use the previously illegal techniques on our fellow Tennesseans? Are any state legislators, with their government-paid health benefits, willing to accept such cutbacks for themselves and their families? There is some suspicion that, because government dollars are fungible and the medical needs of poor people are so unpopular in the legislature, that Amendment 42 could become a piggy bank for other state spending. Is it moral to squeeze the TennCare MCOs to squeeze the state’s poor for more money? The waiver request explicitly says that it won’t spend expected savings on “tourism development, financial institution regulation, or routine infrastructure maintenance…” but that’s hardly reassuring. Robbing the poor to pay for those things would be beyond cruel. 4. One of the gravest dangers of this radical waiver request is reducing the little transparency we have into the workings of TennCare. There are no safeguards in the proposal to help Tennesseans monitor the effects of proposals such as the closed drug formulary that has never been allowed in any Medicaid program. What if your lifesaving drug is not on the list? And it’s not likely to be with only one drug per disease? The waiver request does mention hiring “an independent evaluator” but that seems to be for internal use, not for public information. From its first days, TennCare lacked transparency because the state did not want anyone to know its many management difficulties, such as herding everyone into managed care or refusing to get the reimbursement levels right for six years. Today, TennCare does not want to emphasize the poor health of Tennesseans. Even TennCare seemed surprised recently at the unexplained drop in child enrollees. Forget about getting a list of reimbursement levels for providers. No one seems to have cracked down on Medicaid millionaires. Interestingly, the only 6 mention of Medicaid fraud in the application refers to poor individual patients, not rich health care providers. They get a free pass. Any worthy waiver proposal should be completely transparent to the public. Experimentation may make sense, if it is a genuine experiment. But if it is just sweeping the problems of the poor under the rug, then it is exploitation, not experimentation. Conclusion Tennessee should be granted a waiver, but some modification of former Gov. Haslam’s “Insure Tennessee” waiver request, and not this dangerous proposal. Our state should not be part of this radical Trump-inspired plan to further damage the health of Tennesseans and close more of our hospitals. Our state should focus on getting everyone in Tennessee health insurance coverage instead of unleashing managed care organizations to squeeze savings from the poor. At the very least, CMS should deny the worst parts of the waiver request and should force Tennessee to go back to the drawing board. Tennessee would be wisest to do what Seema Verma did when Mike Pence was governor of Indiana: simply expand Medicaid. Our hospitals are closing, families are going bankrupt from medical expenses and people are dying. This is not the time for more state government experiments. It is not too late to get Tennessee back on the path to better health and stronger hospitals. ### 7 Jonathan Reeve From: Sent: To: Subject: Attachments: John Ray Clemmons Wednesday, October 9, 2019 1:23 PM PUBLICE NOTICE TENNCARE From Rep. John Ray Clemmons 20191009133046096.pdf From Rep. John Ray Clemmons.  1 Jonathan Reeve From: Sent: To: Subject: Attachments: Martin, Richard Lewis Friday, October 18, 2019 4:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] ATTN: Director Gabe Roberts: Richard Martin Comments in Opposition to TennCare Demonstration Amendment 42. Amendment 42 Comments_RM_SR (Rubinstein, Samuel Matthew) (Martin, Richard Lewis).docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts,   Please see attached.  Appreciate your offer to receive public comments on this critically important issue.    Regards,  RM    1 Director Roberts,    I am a hematology/oncology physician in Nashville, TN with deep concerns about Amendment 42.   Amendment 42 rationalizes its necessity by claiming that 1) “in general” states do a “better  job”, and 2) Tennessee deserves more fair compensation from the federal government.    This claim that states inherently do a ‘better job’ is founded on an ideology that with newly  realized flexibilities, the state will drive innovation and enhance performance. The lay summary  promises that these innovations "do not rely on cuts to eligibility or benefits to achieve  savings." After reading Amendment 42, however, it is clear that this proposal requests  numerous cuts to both eligibility and benefits, and in several cases, predicts that these cuts will  result in "savings" and will "maximize resources.” Amendment 42 provides no justification for  cutting these benefits other than calling them "common‐sense" reforms.     Examples include, but are not limited to, the following:      Cutting Medicaid eligibility for those convicted, plead guilty, or even with  deferred/waived convictions of Medicaid fraud.   Exemption from adhering to future federally mandated eligibility expansions.    Determining eligibility and benefits for newly identified Medicaid populations without  requiring either meet current minimum standards.   Cutting pharmaceutical benefits by restricting choices to a single drug per class.   Varying benefits packages within Medicaid subgroups such that benefits only match the  "most relevant needs" of the enrollee.    Redirecting services known to be beneficial to all groups and thus currently required to  be available to all groups, to targeted groups while leaving others behind.    Cutting optional benefits, and restricting in amount, duration, and scope both optional  and mandatory benefits.    The above proposals are incredibly disturbing. It is unclear how these proposals make the state  better or more deserved of federal funds. On the contrary, anyone reading the innovations in  Amendment 42 would conclude that TennCare members are going to be significantly harmed  by this proposal.    With alarming regularity, I meet uninsured or underinsured patients who, fearing bankruptcy  because they lack sufficient coverage, delay seeking care for a symptom which is ultimately  found to be cancer. Due to these delays, the cancer is more advanced, less curable, requires  more toxic treatments, and has a higher likelihood of causing irreversible disability or death. In  fact, just last week, I had to tell an uninsured housing builder who delayed seeking care for fear  of losing his job, that his right arm will need to be amputated to save his life. To be clear, under  PPACA eligibility, this gentleman would have qualified for Medicaid, and had he sought care  earlier, his arm could have been saved. Tennessee’s refusal to participate in the PPACA is very  likely partly responsible for the lifetime of pain and suffering this man will now endure.    As cancer doctors, we are often provided assurances from the state that our cancer patients  will be exempt from any draconian cuts. Carving out benefits for patients only after they are  diagnosed with a life‐threatening disease is neither sufficient nor appropriate. The most  impactful ways to fight cancer are prevention and early detection. This means ensuring cancer  free patients receive comprehensive preventive services, asymptomatic patients receive  evidence‐based screenings, and symptomatic patients can seek immediate care.    Furthermore, many of our life‐saving cancer treatments can only be given to patients with  healthy hearts, lungs, livers, and kidneys. Restricting benefits for chronic diseases will result in  more poorly controlled heart failure, chronic kidney disease, COPD, and cirrhosis, and prevent  my patients from receiving life‐saving treatments.     The authors themselves acknowledge they are not sure whether Amendment 42 will actually  hurt people. They conclude with a specific request to test a scientific hypothesis that “the  demonstration will not negatively impact access to care or health outcomes for TennCare  members.” In my field as a cancer doctor, changing standards of care requires an  extraordinarily high burden of proof, grounded on years of rigorous prior research showing  consistent results.  Amendment 42 provides no foundational evidence to justify conducting this  experiment. I would never entertain giving a vulnerable patient an experimental treatment  outside of a formal clinical trial, as this would violate the Helsinki accord and my Hippocratic  Oath. It appalls me that the authors of Amendment 42 propose to perform such an experiment  on every Medicaid recipient within the state.      Even more concerning, however, is the possibility that the authors do know Amendment 42 will  harm people, for, after making several requests to cut member benefits, they conveniently ask  that the state no longer be required to "mail minimum essential coverage notices to members.”  Experimenting on vulnerable populations without oversight and approval is a serious violation of international ethics laws and codes of conduct. Asking for up‐front federal block grant funding based on projections of comprehensive benefits  only to knowingly cut benefits and retain savings constitutes Medicaid fraud. Trying to hide these harms by requesting exemptions from oversight and accountability is  cowardly.  Amendment 42 has the audacity to claim it is “a responsible and appropriate policy for  Tennessee" with "solutions that are right for Tennessee, that align with Tennessee values.” Amendment 42 does NOT align with my values. It does NOT align with the values of my  hematology/oncology colleagues. It does NOT align with the values of my patients, and it does  NOT align with the values of the 1.4 million vulnerable people who are in desperate need of a  true medical safety net, not some ideological experiment trying to prove that the state can  make more money by cutting benefits and then secondarily hoping that it won’t harm our most  vulnerable people.  I strongly encourage you and the TN legislature to reconsider moving forward with  Amendment42 Sincerely, Richard L. Martin III, MD, MPH Hematology/Oncology Physician Nashville, TN   Jonathan Reeve From: Sent: To: Subject: Attachments: Balog, Sarah (National Office) Friday, October 18, 2019 1:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] LLS comments on Amendment 42 10_18 LLS TN block grant state comments FINAL.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts,     Thank you for the opportunity to submit comments on the proposed Amendment 42. Please don’t hesitate to contact  me if I can answer any questions.      Thank you,  Sarah Balog      SARAH BALOG   Regional Director, Government Affairs ‐ Southeast  The Leukemia & Lymphoma Society   Office of Public Policy     678‐852‐6383   sarah.balog@lls.org              NOTICE: This message, including all attachments transmitted with it, is for the use of the addressee only. It may contain  proprietary, confidential and/or legally privileged information. No confidentiality or privilege is waived or lost by any  mistransmission. If you are not the intended recipient, you must not, directly or indirectly, use, disclose, distribute, print  or copy any part of this message. If you believe you have received this message in error, please delete it and all copies of  it from your system and notify the sender immediately by reply email. Thank you.   1 i American Cancer Society Cancer Action Network. Medicaid 101. May 7, 2019. Available at: https://www.fightcancer.org/policy-resources/medicaid-101-health-insurance-low-income-americans. ii The Leukemia & Lymphoma Society, Facts 2018-19 https://www.lls.org/facts-and-statistics/overview/childhoodblood-cancer-facts-and-statistics iii Alker J. Pending CMS Guidance on Medicaid Block Grants: Executive Overreach Strikes Again. Georgetown University Center for Children and Families. June 27, 2019. Available at: https://ccf.georgetown.edu/2019/06/27/ pending-cms-guidance-on-medicaid-block-grants-executive-overreach-strikes-again/. iv Bagley N. Tennessee wants to Block Grant Medicaid. Is That Legal? September 17, 2019. Available at: https://theincidentaleconomist.com/wordpress/tennessee-wants-to-block-grant-medicaid-is-that-legal/ Jonathan Reeve From: Sent: To: Subject: Attachments: Shannon Baker Friday, October 18, 2019 10:43 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Re: TennCare II Demonstration Amendment 42 (Project No. 11-W-00151/4) TN Block Grant - Final Comments to TennCare 10-18-2019.pdf Importance: High   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   On behalf of the American Lung Association in Tennessee, I am pleased to submit the attached comments on the  TennCare II Demonstration Amendment 42 (Project No. 11‐W‐00151/4).    Thank you,    Shannon Baker Director, Advocacy American Lung Association in Tennessee Lung HelpLine: 1-800-LUNGUSA Lung.org shannon.baker@lung.org   1 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Michelle Mowery Johnson Thursday, October 17, 2019 8:00 AM PUBLICE NOTICE TENNCARE Hannah Cornfield [EXTERNAL] YWCA Nashville & Middle Tennessee Comments for TennCare Block Grant Proposal FINAL Block Grant Letter and Comments_101619.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Bureau of TennCare,   Please find attached comments on the proposed Medicaid block grant. We appreciate the time the Bureau has spent  holding public hearings and the opportunity to comments as it relates the vulnerable individuals and families we serve.  Please let me know if you are unable to open our attached comments.    Kind regards,  Michelle Mowery Johnson                                                               Michelle Mowery Johnson   Sr. Director of Communications & Advocacy   YWCA Nashville & Middle Tennessee  1608 Woodmont Blvd.   Nashville, Tennessee 37215   (615) 983‐5125 – Office   (615) 424‐0544 – Cell   www.ywcanashville.com     24‐Hour Crisis & Support Helpline 1‐800‐334‐4628                YWCA Nashville & Middle Tennessee is dedicated to eliminating racism, empowering women and promoting peace, justice, freedom, and dignity for all.    1 24 Hour Crisis & Support Helpline 1-800-334-4628 2019 - 2020 Board of Directors October 16, 2019 Rita P. Mitchell, Chair Mr. Gabe Roberts Director, Division of TennCare 310 Great Circle Road Nashville, TN 37243 Amanda Weeks-Geveden, Chair-Elect Sharon K. Roberson, President & CEO Gail Alexander Caroline Bradshaw Rebekah Carroll Monica Cintado-Scokin Kendra Deas Beth DeBauche Cindy Dempsey Jamie Dunham Katharin Dyer Rashed Fakhruddin Lisa Ferrelli David Fischette Beth Fortune Glenn Funk Charles K. Grant Janie Greenwood Harris Sean Henry Rick Holton Rita Johnson-Mills Candice Lee Carla Lovell Wanda Lyle Jamie McPherson Osei Mevs Anne Morgan Tracey Pearson Rusty Powell Lisa Quigley Abby Rubenfeld Tara Scarlett Amber Sims Javier Solano Sunny Spyridon DarKenya Waller Jeffrey Webster Evette White Cynthia Whitfield-Story Kate Wood Dear Mr. Roberts, YWCA Nashville & Middle Tennessee appreciates the opportunity to comment on the proposed Medicaid block grant. We have been a part of the Nashville community for over 120 years. The YW operates the largest emergency domestic violence shelter in the state of Tennessee. The 65-bed Weaver Domestic Violence Center serves more than 500 women and children each year who flee their homes and uproot their lives to escape domestic violence. We also offer trauma informed counseling services and transitional housing support. The women and children we serve access our services after calling the 24-hour Crisis and Support Helpline. We received more than 7,500 calls to this number last year. Only a handful of survivors come to the YWCA Weaver Center with private insurance. About forty percent of the women we serve have no insurance at all. That means nearly half of the survivors trying to heal from the physical and emotional wounds of domestic violence receive their insurance through TennCare. All of the women and children we serve have experienced trauma. Many have lived with and through the abuse for months and even years. Their wounds are both visible and, in many cases, invisible. The women and children we serve need consistent, reliable, comprehensive health care coverage. Please see attached our concerns and ideas for improving health outcomes for the vulnerable people we serve. Regards, Sharon K. Roberson President & CEO 1608 Woodmont Boulevard Nashville, TN 37215 Phone 615-269-9922 Fax 615-385-9754 www.ywcanashville.com 24 Hour Crisis & Support Helpline 1-800-334-4628 Comments on Proposed Medicaid Block Grant October 16, 2019 1. On Page 9 of the Draft Amendment 42, under “Per Capita Adjustments for Member Growth”, TennCare attempts to answer how newly eligible applicants for TennCare who are excluded from receiving TennCare coverage due to expenditure of all of the block grant will receive services since the concept of block grants is that when the funds for the program go to zero, no further services can be offered to those who would be eligible until the next block grant cycle is entered. Currently, once an applicant is determined eligible, services are immediately available and retroactive to the date of application. The original block grant is to be based on “TennCare’s average enrollment in four member categories during a specified base period (State Fiscal Years 2016-2018)”. TennCare proposes that there will be a “per capita adjustment for member growth” and that: If while the demonstration, TennCare’s actual enrollment in any of these categories exceeds the category’s average enrollment during the base period [Fiscal Years 2016-2018], then the state’s block grant will be adjusted on a per capita basis to reflect the increase in membership. The per capita adjustment will be equivalent to the federal portion of the appropriate “Without Waiver” expenditure amount (the same number used to calculate the initial block grant amount for the member category in which enrollment has increased), trended forward by, the inflation factor, and multiplied by the number of additional members above the average base period enrollment. The per capita adjustment ensures the state will continue to be able to provide medical assistance to all eligible individuals, regardless of changes in the economy or other factors outside the state’s control that may result in an increase in TennCare enrollment. What is not addressed is: a. How much of an increase in enrollment would be needed to trigger the adjustment, one person or one hundred persons? and b. How long will it take TennCare and the Centers for Medicare and Medicaid Services (CMS) to agree on the funding change and make this adjustment to the block grant? Federal reviews on program changes and new funding proposals are not known for their timeliness. In the meantime, persons needing medical care and who are otherwise eligible, could be on the outside looking in on services for which they are eligible, but for which there is no available funding, pending agreement by TennCare and CMS on the numbers of eligibles in each affected category and the per capita 1608 Woodmont Boulevard Nashville, TN 37215 Phone 615-269-9922 Fax 615-385-9754 www.ywcanashville.com 24 Hour Crisis & Support Helpline 1-800-334-4628 amount for that category and the receipt of CMS’ blessing on TennCare’s proposed funding adjustment. It could be that those persons may be unable to obtain medical treatment during the interim. Will, then, TennCare hold these eligibles harmless and provide state funding via a supplemental state appropriation for medical care during this waiting period? This should be clarified by TennCare in its proposal to CMS. 2. On Page 15 of the Draft Amendment 42, under “Delivering the Right Care to the Right Members”, TennCare advocates the change in federal policy that currently requires the same services be offered to all recipients, and wants to be allowed to offer services directed toward the needs of a specific population. If approved by CMS, this offers the opportunity for the YWCA to advocate for TennCare services to be made available to victims of domestic violence who are without insurance or the means to obtain insurance because they have lost their means of support and, presumably would need to be certified to be a DV victim by the YWCA and/or law enforcement. It would be appropriate to raise this possible new category at each level of comment, i.e., during this initial period ending on October 18, then, during the federal comment period as CMS considers the State’s proposal, as well as with legislators who must approve by resolution the plan agreed to by CMS and TennCare. There is still another opportunity again with the legislators who, later in the Joint Government Operations Rules Review hearings will be reviewing TennCare’s proposed rules implementing the block grant program, and testimony could be provided by the Y and other interested groups in support of this category. 3. On page 16 of the Draft Amendment 42, under “Delivering the Right Care to the Right Members”, TennCare states that it is “not the intent under this proposal to reduce covered benefits for members below their current levels”. The proposal strongly suggests that the federal approval process is “unnecessarily limiting and constrains” TennCare’s ability to develop new means of providing different packages of services to different groups because of the federal requirement of “comparability” which mandates the same “amount, duration and scope” of services for all eligible populations, and, therefore, limits TennCare’s ability to “explore new therapies and treatment modalities” and “develop pilot programs designed to assess their clinical efficacy and potential cost effectiveness” [See page 15]. While this new flexibility would appear to make possible the provision of TennCare services to DV victims noted in #2 above, on the other hand, it does not explain how TennCare will develop and fund these new/different services without affecting some services in the packages offered currently. Presumably, these new services could be funded by the savings TennCare believes that will result from its greater flexibility in targeting services differently for different groups’ medical needs and/or the 50% retention of savings gained in the block grant process as proposed by TennCare, but how these possible sources of funding will become available for these new “therapies and treatment modalities” is not otherwise specifically discussed in this section. We are left to wonder if current service packages, including the types and amounts of prescription drugs offered, will be reduced in order to direct experimental programs or therapies, or, for treatments for health crisis issues such as the opioid problem rather than seeking specific, separate, appropriations to address additional serious chronic or new health crises. 1608 Woodmont Boulevard Nashville, TN 37215 Phone 615-269-9922 Fax 615-385-9754 www.ywcanashville.com 24 Hour Crisis & Support Helpline 1-800-334-4628 This should also be addressed in the proposal. 4. Finally, the potential illegality of the block grant proposal may cause the state of Tennessee to be embroiled in expensive, protracted litigation. In an article from the Chattanooga Times Free Press dated September 18, 2019, the basic legality of the concept of block granting any Medicaid program has been questioned by a University of Michigan law professor, Nicholas Bagley. He states: "…setting aside the dubious policy merits of block grants, however, I don't think the proposal is legal. "I don't even think it's close," added Bagley, who posted his views Tuesday on The Incidental Economist, a health policy blog. … Bagley, a former appellate staff attorney in the Civil Division at the U.S. Department of Justice who previously served as a law clerk to U.S. Supreme Court Justice John Paul Stevens, says he sees a problem in the state's concept for the waiver. Under section 1903[of the Social Security Act, Section 42 United States Code, Section 1396b] of the Medicaid statute, he says, the federal government "must pay a fixed 'match rate' (known in the statutory lingo as 'the Federal medical assistance percentage') to every state that participates in Medicaid." Tennessee's match rate is now 65.21%, meaning that for every $1 the state spends on TennCare, Uncle Sam provides a little over $2. That, however, would change under a number of different TennCare programs under [Governor] Lee's proposed waiver. "As Tennessee recognizes," Bagley writes, "it'll need a waiver from HHS to make these changes. And section 1115 [of the Social Security Act; 42 United States Code Section 1315] of the Medicaid statute does allow HHS to waive lots of the law's restrictions in connection with experimental projects that are likely to assist in promoting Medicaid's objectives." Acknowledging that he's previously written he isn't sure "block granting Medicaid counts as an experiment that serves Medicaid's purposes," the New York University of Law graduate whose writings have appeared in the Harvard Law Review, Columbia Law Review, Georgetown Law Journal and New England Journal of Medicine, goes on to say "there's a more fundamental problem with Tennessee's proposal. "You can't use section 1115 to waive section 1903," he says. "To the contrary, section 1903 is pointedly omitted from the list of statutory provisions that HHS is empowered to waive. "So, you can't use Medicaid waivers to change Medicaid's financing structure. And that's exactly what Tennessee is proposing to do," Bagley adds. 1608 Woodmont Boulevard Nashville, TN 37215 Phone 615-269-9922 Fax 615-385-9754 www.ywcanashville.com 24 Hour Crisis & Support Helpline 1-800-334-4628 He is correct that the financing provisions of the Medicaid law are omitted from Section 1115’s waiver authority under subsection (a) paragraph (1). The statute reads: SEC. 1115 [of the Social Security Act.] [42 United States Code Section 1315] (a) In the case of any experimental, pilot, or demonstration project [TennCare] which, in the judgment of the Secretary, is likely to assist in promoting the objectives of title I [OldAge Assistance], X [Aid to the Blind], XIV [Aid to the Totally & Permanently Disabled], XVI[SSI], or XIX [Medicaid], or part A [TANF/Families First]or D[Child Support] of title IV [Grants to States for Aid and Services to Needy Families with Children and for ChildWelfare Services], in a State or States— (1) the Secretary may waive compliance with any of the requirements of section 2 [SSA], 402 [State Plans under Title IV-A/TANF/Families First], 454 [State Plan for Child Support], 1002 [State Plans for Aid to Blind], 1402 [State Plans for Aid to the Totally and Permanently Disabled], 1602 [State Plans for Aid to the Aged, Blind and Disabled/SSI], or 1902 [State Plans for Medical Assistance] as the case may be, to the extent and for the period he finds necessary to enable such State or States to carry out such project, and As stated by Professor Bagley, Section 1903 is clearly not included in the waiver provisions permitted by subsection (a)(1) of Section 1115. In addition, the October 01, 2019 edition of The Tennessean also now reports its own interview with Professor Bagley, that essentially confirms his earlier statement to the Free Press. Noting that the 2017 attempt to repeal the Affordable Care Act which included requiring block granting of State Medicaid programs failed, there appears in the article an additional, perhaps more problematic, issue involving legality of implementing Medicaid block grants. The article notes that among those now opposing the attempts by States to use block granting is U.S. Rep. Frank Pallone Jr., D-N.J., chairman of the House Energy and Commerce Committee whose committee has jurisdiction over Medicaid program provisions, and the article quotes Rep. Pallone saying: “Block granting Medicaid through a waiver is illegal, and the Trump administration does not have the authority to approve Tennessee’s request,” Pallone said Wednesday in a statement to the USA TODAY Network, declaring that “Tennessee and the Trump administration are attempting to bypass Congress and the American people.” The article continues: 1608 Woodmont Boulevard Nashville, TN 37215 Phone 615-269-9922 Fax 615-385-9754 www.ywcanashville.com 24 Hour Crisis & Support Helpline 1-800-334-4628 Pallone in June sent a letter to U.S. Department of Health and Human Services Secretary Alex Azar explaining that he believes federal law does not currently permit him to approve such a measure. The article does not say what statutory provisions of the law, or lack thereof, Rep. Pallone states render block grants illegal for the Medicaid program. Though the waiver of provisions of the financing law of Section 1903 does not appear in Section 1115(a)(1) of the Social Security Act] [42 U.S.C. Section 1315] which permits waiver by HHS of certain statutory provisions governing a State Medicaid Plan (among several others programs), Section 1903(a)(2) of the Social Security Act [42 U.S.C. Section 1396a(a)(2)] regarding requirements for State Plans for Medical Assistance does contain the following language relative to funding requirements: 1902(a)(2) A State plan for medical assistance must— (a) … (2) provide for financial participation by the State equal to not less than 40 per centum of the non-Federal share of the expenditures under the plan with respect to which payments under section [42 U.S.C, Section 1396b [Section 1903 of the Social Security Act][42 U.S.C. 1396b] of this title are authorized by this subchapter; and, effective July 1, 1969, provide for financial participation by the State equal to all of such non-Federal share or provide for distribution of funds from Federal or State sources, for carrying out the State plan, on an equalization or other basis which will assure that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope, or quality of care and services available under the plan; This is one of literally dozens of operating standards to which a State Medicaid program must adhere unless waived pursuant to Section 1115. But subsection (a)(2) of Section 1115 has language relating to funding of State Plans for which waivers are granted. Section 1115 of the Social Security Act/42 U.S.C. 1315(a)(1) & (2) states: (a) In the case of any experimental, pilot, or demonstration project [TennCare’s program] which, in the judgment of the Secretary, is likely to assist in promoting the objectives of title I [Old-Age Assistance], X [Aid to the Blind], XIV [Aid to the Totally & Permanently Disabled], XVI[SSI], or XIX[ Medicaid], or part A [TANF/Families First]or D[Child Support] of title IV [Grants to States for Aid and Services to Needy Families with Children and for Child-Welfare Services], to enable such State or States to carry out such project. and 1608 Woodmont Boulevard Nashville, TN 37215 Phone 615-269-9922 Fax 615-385-9754 www.ywcanashville.com 24 Hour Crisis & Support Helpline 1-800-334-4628 (1) the Secretary may waive compliance with any of the requirements of section 2 [SSA], 402 [State Plans under Title IV-A/TANF/Families First], 454 {State Plan for Child Support], 1002 [State Plans for Aid to Blind], 1402 [State Plans for Aid to the Totally and Permanently, Disable], 1602 [State Plans for Aid to the Aged, Blind and Disabled/SSI], or 1902[ State Plans for Medical Assistance] as the case may be, to the extent and for the period he finds necessary to enable such State or States to carry out such project, and (2)(A) costs of such project which would not otherwise be included as expenditures under section 3, 1003, 1403, 1603, or 1903[Medicaid], as the case may be, and which are not included as part of the costs of projects under section 1110, shall, to the extent and for the period prescribed by the Secretary, be regarded as expenditures under the State plan or plans approved under such title, or for administration of such State plan or plans, as may be appropriate, and… Although no specific waiver authority from the standard match financing requirement process in Section 1903 is provided in Section 1115(a)(1), it could be argued that under paragraph (2) of subsection (a) of Section 1115 that if a waiver from the Medicaid State plan requirements is made for Tennessee under subsection (a), paragraph (1) of Section 1115 to carry out a demonstration project, then paragraph (2)(A) of subsection (a) of Section 1115 states that any state Medicaid plan that is normally subject to Section 1903’s funding requirements, could have the costs of the demonstration project be treated as if they satisfied the funding requirements for Tennessee’s Medicaid State Plan under Section 1903(a)(2). Although Amendment 42 does not address the explicit justification for block grant funding versus the match process, this may be what TennCare is basing the waiver of current funding requirements that would then permit the use of a block grant for Tennessee’s TennCare program. The specific basis under Section 1115 for the block grant funding mechanism should be clearly explained by TennCare. 1608 Woodmont Boulevard Nashville, TN 37215 Phone 615-269-9922 Fax 615-385-9754 www.ywcanashville.com Jonathan Reeve From: Sent: To: Subject: Attachments: Sheila Taylor Friday, October 18, 2019 12:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Letter of Support for MH Funding TennCare Letter.docx Importance: High   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Sheila L Taylor, MA LPC Clinical Coordinator Lifecare FITT(Family Intervention Treatment Team) Program 615-426-8269 "Act as if what you do makes a difference. It does" ~ William James 1 October 11, 2019 Dear TennCare officials, TennCare is important to me and the many clients I serve. It provides comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare has helped so many young people and those in need by providing their physical AND mental health needs. Without TNCare my program would not be able to help children heal in their homes instead of hospitals and residential programs. The best place to help many of our suicidal youth and adults is by providing help right here in their community and in their home. Without TennCare programs such as my own, Lifecare Family Services, Omnicommunity Health, Centerstone, Mental Health Cooperative and etc. will not survive. We will have more people in hospitals and residential settings as well as jails. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely, Sheila L Taylor  Sheila L Taylor, MA Licensed Professional Counselor   Jonathan Reeve From: Sent: To: Subject: Attachments: TEENA COHEN Wednesday, September 18, 2019 3:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare block grant proposal Mr Gabe Roberts.docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please see attached letter sharing my concerns related to the TennCare block grant proposal. Thank you, Teena Cohen 1 Mr. Gabe Roberts, Director: My first response to the article with further details regarding the potential block grant for TN relates to one of the dates selected for public hearings. The day mentioned in the Tennessean article is Oct.1 at Family and Children's Service location. That date is poorly chosen, as it is the second day of Rosh Hashanah, the Jewish New Year. I do believe we are all citizens of TN, no matter our religious faith, and this date selected is not respectful of members of the Nashville/Middle TN Jewish community. As I have read the "fine print" of what is known at this time related to the block grant being considered, I am totally against this approach to the healthcare of the most needy and vulnerable among us!! What is being promoted is to "save" money, which appears to translate to the reality of cutting back on services for TennCare clients and limiting the number of clients allowed into the program. The article in today's Tennessean states, "Among these exclusions are care provided to individuals with intellectual disabilities, children in state custody and patients who are dually enrolled in TennCare and Medicare." Additionally, "the plan excludes TennCare's prescription drug costs, uncompensated care payments to hospitals and administrative costs incurred throughout the program." While I consider myself to be somewhat informed on local issues, it is still baffling to me that our 'Volunteer' state of TN did not make the wise choice to expand Medicaid when the opportunity was present!! Funds to our state would have helped to better the lives of those needing this program without huge exceptions as are evident in the block grant option. Thank you for listening/reading, Teena Cohen Nashville 37205 Jonathan Reeve From: Sent: To: Subject: Attachments: Libby Thurman Friday, October 18, 2019 1:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on Amendment 42 TPCA Comments to State on Block Grant - 10-18-19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   The Tennessee Primary Care Association is pleased to provide comments on Amendment 42. Please see the  attached letter.    Thank you,  Libby Thurman          Libby Thurman, Chief External Affairs Officer  710 Spence Lane, Nashville, TN 37217  Direct Phone: (615) 425‐5848   Direct Fax: (615) 425‐5878  libby.thurman@tnpca.org  www.tnpca.org    The Tennessee Primary Care Association improves access to  health care through leadership, advocacy, and support as the  voice of Community Health Centers.  The contents and attachments contained in this e‐mail are intended to  be privileged and confidential information solely for use by the  individual(s) named above. If you have received this e‐mail in error,  immediately notify the sender by reply e‐mail and delete the message  and its attachments from your system. You should not reproduce,  disseminate, distribute, or copy the e‐mail message or attached  documents.      1 Jonathan Reeve From: Sent: To: Subject: Attachments: Anness, Nancy Friday, October 18, 2019 3:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Ascension Saint Thomas Comment Letter regarding Amendment 42 Section 1115 TennCare II Demonstration Ascension Saint Thomas Comment Letter Amendment 42 Section 1115 TennCare II Demonstration 10.18.19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good Afternoon,     Ascension Saint Thomas appreciates the opportunity to submit comments regarding Amendment 42 to Section 1115  TennCare II Demonstration, the proposed waiver amendment.  Please see the attached comment letter.    Thank you,  Nancy Anness    Nancy Anness  Chief Advocacy Officer  Ascension Saint Thomas  102 Woodmont Blvd. Suite 700  Nashville, Tennessee 37205   (615) 284‐6819  nanness@ascension.org            CONFIDENTIALITY NOTICE: This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege.   1 Jonathan Reeve From: Sent: To: Subject: Attachments: Bailey Schiermeyer Friday, October 18, 2019 2:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Amendment 42 Comment Block Grant Ltr from NALEA Chapter.2019.10.18.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good afternoon, Please see attached. Thank you. Sincerely,   Bailey Schiermeyer, JD Life Care Planning Attorney www.elderlawetn.com    Greater Knoxville 865-951-2410 903 N. Hall of Fame Drive Knoxville, TN 37917 Tri-Cities 423-301-6551 1907 N. Roan Street Suite 406 Johnson City, TN 37601 Jana Huddleston is my paralegal. Please contact her with questions or to schedule appointments at (865) 313-2038 or jana@elderlawetn.com.     1 Jonathan Reeve From: Sent: To: Subject: Attachments: Bailey Schiermeyer Friday, October 18, 2019 3:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Second submission on behalf of TN NAELA Block Grant Ltr from NALEA Chapter.2019.10.18.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Attached please find a revised version of our comments letter. Thank you. Sincerely,   Bailey Schiermeyer, JD Life Care Planning Attorney www.elderlawetn.com    Greater Knoxville 865-951-2410 903 N. Hall of Fame Drive Knoxville, TN 37917 Tri-Cities 423-301-6551 1907 N. Roan Street Suite 406 Johnson City, TN 37601 Jana Huddleston is my paralegal. Please contact her with questions or to schedule appointments at (865) 313-2038 or jana@elderlawetn.com.     1 Jonathan Reeve From: Sent: To: Subject: Attachments: Tom Starling Monday, October 14, 2019 1:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] MHA's perspective of block grant amendment Medicaid Block Grant letter.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you for including my attached feedback about TennCare Waiver Amendment 42.    Respectfully,    Tom Starling, Ed.D.  President/CEO    Mental Health America of MidSouth (Formerly Mental Health Association of Middle TN)  446 Metroplex Dr, Suite A-224, Nashville, TN 37211  1350 Concourse Ave, Ste 142, Memphis, TN 38104  Main Phone: 615-269-5355  Main Fax: 615-269-5413  www.mhaMidSouth.org             Confidential Notice: The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential, proprietary, and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from all computers.    1 MW Mental Health America of the MidSourh October 74,2OI9 Gabe Roberts, Director Division of TennCare vio emøil to; public.notice.tenncare@tn.gov RE: TennCare Waiver Amendment 42 Dear Director Roberts, As CEO of Mental Health America of the MidSouth (MHA), I am submitt¡ng the following comments in response to the public notice inviting public comments on proposed Waiver Amendment 42. MHA's programs focus on suicide prevention, Alzheimer's support, recovery from human trafficking, antibullying in schools, screenings, professional workshops, community education, and a helpline for information and referrals. MHA supports prevention, early intervention, integrated care treatments, and recovery for all. MHA does not support TennCare Waiver Amendment 42. Block grants are synonymous with "caps," and Tennessee is a vibrant, growing state. I truly believe this route will lead to less care, limited care, and not support the health needs of vulnerable populations who most need TennCare services. While the block grant will offer flexibility, I do not believe that it will offer the savings that our legislature is hoping. MHA specifically objects to any caps or limitations of prescription drugs or medication access, including step therapy, which overrides a physician's care by trying cheaper, less effective medications. When treating mood disorders, one size does not fit all. DBSA encourages TennCare to provide beneficiaries a clear appeals process and consumer protections for any changes made to their prescription drug formulary. Unlike a broken bone that could use a split or a cast, mental illnesses are complex and require immediate, accurate treatment. MHA respectfully urges you not to go forward with TennCare Waiver Amendment 42 Sincerely, / {7\ Tom Starling, EdD President and CEO 1350 Concourse Ave, Suite 142 446 Metroplex Dr, Suite A-224 - Memphis, TN 38104 - (615) 269-5355 - Nashville, TN 37211 - (615) 269-5355 Jonathan Reeve From: Sent: To: Subject: Tony Garr Sunday, October 6, 2019 5:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment #1: Tennessee Does Not Need a Block Grant to Save Billions in order to Keep Half of It   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   One of the reasons for Tennessee asking for a Block Grant is that none of the money that it is saving the federal  government now, and has since its inception in 1994, is coming back to the state. All the funds that TennCare has saved  the federal government has reverted back to the federal government. TennCare claims that the savings to the federal  government since 1994 are in the billions.    If this is the case, then why not ask that these savings be shared with Tennessee as part of the current 1115 waiver  using its current funding/matching agreement? Why would Tennessee want to unnecessarily restrict funding from the  federal government by asking for a Block Grant to retain some or part of the savings? Amendment 42 makes the  argument that TennCare has saved the federal government billions and that the incentives are misaligned, meaning that  the more the state spends on its Medicaid program, the more the federal government will spend according to the match  rate. In Tennessee, this match rate is about 35% State and 65% federal funds. So, Tennessee argues that if the state is  willing to take the risk and Cap what it gets from the federal government, then, if successful, it needs to benefit  financially from these savings. The state is asking that it should be able to retain 1/2 of all the savings.  TennCare has proven that it can run a very efficient program and that it can keep its spending below the neutrality cap  that is pre‐determined by the Congressional Budget Office. It has been able to do this since the beginning. Of course,  TennCare is incentivized to do this because if it goes over its neutrality budget cap, then it will have to go back to the  state legislature and ask for supplemental funds, a common practice before the creation of TennCare in 1994. In  addition, if TennCare goes over its neutrality cap, then TennCare would lose its federal match and would be required to  pay 100% of the costs above the neutrality cap.  Since the inception of Medicaid in 1965 in Tennessee, it was a common occurrence for its Medicaid program to ask for  supplemental funding during the year in addition to its annual budgeted funds from the state legislature. This occurred  because medical inflation was and still is about twice that of regular inflation and tax dollars were not and have never  increased at twice that of regular inflation. To stay within its budget, its Medicaid program, which was primarily a fee‐ for‐service program, would either cut benefits, cut reimbursement to doctors and hospitals, or ask for supplemental  funds. When reimbursements were reduced to providers, the likely scenario was that providers would drop out of the  Medicaid program and no longer accept Medicaid.  When benefits were cut or reduced (for example: hospital stays  being restricted to 10 days/year), it would result in many hospitals not getting paid for patients who needed more than  10 inpatient days.  Providers would have to either not provide the care, shift the costs to paying patients, or reduce the  amount of care.   With the creation of TennCare in 1994 and the conversion from a fee‐for‐service to a managed care organization system,  and after about a decade of turbulent start‐up years with unstable managed care organizations, TennCare  finally  developed a stable, mature network of MCOs. This stabilized the TennCare budget, making it more predictable and  easier to budget. Since 1994, the managed care organizations, not the state, had been at risk for losing money.  1 Now the state is proposing a Block Grant through Amendment #42 which operates like a Capitation Program, putting the  TennCare program at risk because the amount that it will receive from the federal government will be fixed, based on  the number of people being served, with inflation being based on ordinary inflation not medical inflation which is always  higher. TennCare is saying that its track record is such that this is not a concern, that no one will lose their care and  providers will not be cut.  This begs the question: Why is Tennessee requesting a Block Grant when the program can continue to be efficient and  save money despite medical inflation? Why not just ask the federal government for half the savings that it creates  annually under the current funding/matching agreement?  Take care,    Tony Garr  259 Graylynn Drive  Nashville, TN  37214  tgarrthcc@gmail.com  615‐603‐9747      2 Jonathan Reeve From: Sent: To: Subject: Tony Garr Friday, October 18, 2019 2:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment #2: Public Comment on TennCare's Proposed Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I’ve been studying health insurance reform in Tennessee for 43 years. It has been my focus every day. I’ve read opposing  and supporting views on how to improve affordable, accessible, and access to care, specifically in Tennessee. The  leading, nationally recognized organization on this issue, the Kaiser Family Foundation, has looked at health reform  extensively across the country. You might argue that Amendment #42 is about improving outcomes and saving money  for those enrolled.  Yes, you are right about saving money for TennCare and improving current enrollees health. Yet,  Amendment #42 will not improve the health outcomes of all Tennesseans because you are leaving out 300,000 folks. In  addition, even though TennCare may be saving money, thousands of Tennesseans and their families are going bankrupt  and without care, especially in rural Tennessee.  If TennCare is saving both federal and state dollars now, then expansion would save more dollars. In addition, expansion  goes much further than improving health and saving money. Expansion in other states has proven to reduce the cost of  care, reduce premiums in the ACA individual insurance marketplace, and increase by 80% the survival of rural hospitals.  The biggest bang for the Tennessee dollar is to expand services.   Today, 36 states have expanded its Medicaid program. In 2014, when states had the choice to expand coverage, 27  states, including the District of Columbia, did. Of the 36 states that have expanded, more than half of these states were  states controlled by Republican legislatures. Four prime examples are republican governors and former governors: Chris  Christie, (New Jersey), Mike Pence (Indiana), Jan Brewer, (Arizona), and John Kasich, Governor of Ohio.  Since 2014, 9 more states have chosen to expand its Medicaid program and no state has chosen to end its expansion.  Many republican states have placed two conditions in their law that could have forced the ending of their expansion: 1.  If the federal matching rate should ever go below 90%, then the program would end; and 2. The legislature has had to  re‐authorize the program each year. Neither of these two have happened, even in republican controlled states.  This choice that 36 states have made to expand coverage has created the perfect laboratory for research, comparing  states that have or have not expanded. Over 324 studies have been conducted by states, universities, and health care  policy institutes. The KFF has compiled a compilation of these studies and have concluded.  Research indicates that the expansion is linked to gains in coverage; improvements in access, financial security, and  some measures of health status/outcomes; and economic benefits for states and providers.     Coverage: Studies show that Medicaid expansion states experienced significant coverage gains and reductions in  uninsured rates among the low‐income population broadly and within specific vulnerable populations.   Access to care and related measures: Most research demonstrates that Medicaid expansion has improved  access to care, utilization of services, the affordability of care, and financial security among the low‐income  population……  1  Economic measures: Analyses find effects of expansion on numerous economic outcomes, including state  budget savings, revenue gains, and overall economic growth. Multiple studies suggest that expansion can result  in state savings by offsetting state costs in other areas….  In the 14 states that have not expanded, with Tennessee being 1 of the 14, the most common characteristics are that  these states are dominated by republican legislatures and they are in the Southeast. The only states in the Southeast  that have expanded are Kentucky, Arkansas, and Louisiana. Several more states will conduct ballot initiatives.  Oklahomans Decide Health Care just completed their petition drive this week to get on the 2020 ballot in Oklahoma  which will likely be approved by the voters. Florida will conduct such a drive in 2022. It is also likely that two additional  states, Wisconsin and North Carolina, will pass expansion in 2020 or after the elections. Then Tennessee will be 1 of the  11 that continues to choose to not expand.  This compilation of 324 studies show gains of coverage for those who are most vulnerable in rural areas. With rural  development being one of Tennessee's most important concerns, expansion has made the biggest difference in rural  areas. When Tennessee entices national and international companies to locate in Tennessee, aside from the question  about a workforce, they ask questions about the quality of local schools and access to healthcare.  In addition, no state has passed Medicaid without the support of its governor except those states which have done so  through ballot initiatives. However, Tennessee’s constitution does not allow for a ballot initiative. Tennessee needs to  study why expansion is a better alternative and its legislature and governor needs to provide the leadership.  There is more. After a dramatic and steady drop in the uninsured rate in Tennessee since 2014, the number of uninsured  in Tennessee has risen in 2017 and then again in 2018, including children. The recent study by UT confirms this finding  and its disturbing trend. https://haslam.utk.edu/sites/default/files/tncare19.pdf  If we want to improve health outcomes and save money, then block granting TennCare is not what Tennessee needs to  be doing. We need to expand care to the 300,000 low‐income working Tennesseans so that all Tennesseans, especially  rural citizens and hospitals, will benefit. This should not be about Tennessee, but about its citizens and the state as a  whole.  The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review: Larisa Antonisse, Rachel Garfield Follow  @RachelLGarfield on Twitter, Robin Rudowitz Follow @RRudowitz on Twitter, and Madeline Guth  Published: Aug 15, 2019, https://www.kff.org/medicaid/issue‐brief/the‐effects‐of‐medicaid‐expansion‐under‐the‐aca‐updated‐findings‐from‐a‐ literature‐review‐august‐2019/   2 Jonathan Reeve From: Sent: To: Subject: Tony Garr Friday, October 18, 2019 3:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment #3: TennCare has become a very efficient program for those whom it serves, but WHY?   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   TennCare has become a very efficient program for those whom it serves, but WHY?    As of today, TennCare is recognized as one of the top Medicaid programs in the country. Its MCOs are certified; it has  one of the lowest rates per capita member in the country; and the Annual Survey of members conducted by the  University of Tennessee gives TennCare high marks. However, it has not always been that way.     As a start‐up program in 1994 and for its first 10 years, Managed Care Organizations failed, doctors and hospitals did not  get paid, provider networks were weak and in some cased non‐existent, and patients could not find doctors to treat  them (patients were being transported from East Tennessee to Nashville to get treatment and surgery). In addition, with  a few exceptions, TennCare’s Directors were unqualified and did not serve the program well.    However, TennCare did finally settle in and under the direction of Darin Gordon, the program was stabilized. Because of  the upheaval in the first 10 years or so, TennCare also faced numerous lawsuits because of the lack of services being  provided and the lack of a member appeal process. Over time, Darin Gordon worked through these lawsuits and  stabilized the program.    What is important to remember and understand is that TennCare is an efficient program today because of the federal  Medicaid regulations and the class action lawsuits brought against it. Sure, regulations and lawsuits were irritants and  no‐one at TennCare would likely tell you that these irritants have made TennCare better, but they did. If it were not for  the federal regulations, and the class action lawsuits, TennCare would not be as good as it is today.     As TennCare moves forward, why would Tennessee/TennCare want more flexibility and want to abandon many of its  regulatory oversight? There is only one answer. TennCare is doing this because the state legislature has passed a law  telling them that they have to do this. This gets to the core of Amendment #42.    This is not about TennCare. It is about the state legislature wanting not to be restricted by federal regulations as to the  eligibility categories that the State is mandated to cover and the benefits that it is required to provide. If Amendment  #42 is approved, it will open up the flood gates for our legislature to micro‐manage TennCare. TennCare may complain  about the regulations in the current waiver. However, this is nothing compared to the challenge that it would have once  the state legislature gets the green light that it can start telling TennCare who to cover and what benefits it will provide.   This is a very slippery slope. TennCare needs the federal regulations. That is why they have been so successful and there  is no reason to think that they will not be able to continue to be successful under the current waiver. However, taking  away these regulations will open up the door for TennCare to have 132 legislative managers. I do not think that this  would be good for Tennessee nor for the 1.4 million people whom TennCare currently serves.    Take care, Tony Garr 259 Graylynn Drive 1 Nashville, TN 37214 tgarrthcc@gmail.com 615-603-9747     2 Jonathan Reeve From: Sent: To: Subject: Tony Garr Friday, October 18, 2019 4:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment #4: Flexibility? What does this mean for the consumer?   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Flexibility? What does this mean for the consumer?    Currently, when changes are made to TennCare’s waiver when it has its renewed every few years, there is a period for  public comment and rule making. As I look at the public comment process for Amendment #42, there are many steps  before approval.           Step #1: TennCare drafts the proposal;  Step #2: Public comment period;  Step #3: TennCare reviews the pubic comments, makes modifications, and submits its proposal to CMS;  Step #4: CMS reviews the TennCare draft proposal and negotiates another draft approved by CMS;  Step #5: Public comment period for the draft approved by CMS;  Step #6: CMS review the public commit and negotiates a final proposal.    It is worth noting that this Amendment is #42. Each of 41 earlier amendments have undergone a review process and  have been required to have a public comment period. It is unclear if Amendment #42 will be able to waive the public  comment requirement.    Amendment #42 is requesting a great deal of flexibility for eligibility categories and benefits but lacks any mention of  providing pubic comment periods for changes to its program. The current public comment period has evolved over the  years to protect consumers from adverse changes to Medicaid programs that would impact beneficiaries in a negative  way.    Because of the lack of clarity concerning public comment periods for proposed flexibility, Amendment #42 should be  rejected.    Take care,    Tony Garr  259 Graylynn Drive  Nashville, TN  37214  tgarrthcc@gmail.com  615‐603‐9747        1 Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Allison Rollins Wednesday, October 16, 2019 9:35 AM PUBLICE NOTICE TENNCARE jerter@tnonc.com; Burris Howard; Jennifer Brunelle; Gilbert, Jill; Courtney Atnip; Christy Levine [EXTERNAL] ATTN: Director Gabe Roberts: TOPS/ASCO Comments on TennCare Demonstration Amendment 42 TOPS_ASCO_Comments_on_Demonstration_Amendment_42.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts,    Thank you for requesting public comment on TennCare Demonstration Waiver 42, the Tennesee Block Grant Proposal. I  am pleased to be submitting the attached joint comments on behalf of the Tennessee Oncology Practice Society (TOPS)  and the American Society of Clinical Oncology (ASCO). TOPS represents a large community of oncologists and  hematologists that treat TennCare patients affected by cancer. ASCO is the world's leading professional organization for  physicians and oncology professionals caring for people with cancer. Together we are writing to express our concern for  the specialized patient population that we care for and to offer ourselves as a resource to you.    If you have any questions or require further information, please don’t hesitate to reach out.     Best regards,    Allison Rollins, MSc  Specialist, State Advocacy  Policy & Advocacy   American Society of Clinical Oncology  2318 Mill Road, Suite 800  Alexandria, VA 22314   571‐483‐1703    asco.org • cancer.net • conquer.org • cancerlinq.org     Be in the know. Visit ASCO’s State ACT Network and State Advocacy Site.      Making a world of difference in cancer care -------------------------------------------------------------Privacy Notice: The contents of this electronic message, including any prior messages, files, or attachments transmitted with it, are CONFIDENTIAL and are intended solely for the use of the individual(s) to whom the message is addressed. This message may contain legally protected or privileged information. Do not read, copy, disclose or forward this message without authorization from the originator of this message. If you have received this message in error, please notify the sender immediately and delete all copies from your system. -------------------------------------------------------------- 1 October 16, 2019 Gabe Roberts Director, Division of TennCare 310 Great Circle Road Nashville, TN 37243. Dear Director Roberts, On behalf of the Tennessee Oncology Practice Society (TOPS) and the American Society of Clinical Oncology (ASCO) we write to express our strong concerns about TennCare Demonstration Amendment 42 (Medicaid Block Grant Proposal). TOPS is a community of oncologists, nurse practitioners, physician assistants, and other allied health professionals who provide a powerful voice for multidisciplinary cancer care teams and the patients they serve. ASCO is the national organization representing nearly 45,000 physicians and other health care professionals specializing in cancer treatment, diagnosis, and prevention. With the well-being of thousands of Tennessee cancer patients and survivors in mind, we are deeply concerned about the effects that this block grant proposal could have on meaningful access to care for the Medicaid population in Tennessee. ASCO released guiding principles on Medicaid Reform in 2014, including recommendations intended to help state Medicaid programs innovate while maintaining access to high-quality cancer care. Among these recommendations, we call on programs to ensure that enrollees with cancer: • have access to cancer care delivered by a cancer specialist; • have access to cancer screening and diagnostic follow up without copays; • do not face insurance barriers to clinical trial participation; and • receive the same timely and high-quality cancer care as patients with private insurance. Additionally, Medicaid reimbursements should be sufficient to ensure that patients enrolled in Medicaid can have access to quality cancer care. Unfortunately, it is evident that provisions in the Medicaid Block Grant Proposal run counter to our principles. While we acknowledge that the intent of the proposal is to promote innovation and reduce waste, TOPS and ASCO have some concern that the implementation of the following flexibility requests may have detrimental consequences on TennCare’s specialized patient populations: Re-Enrollment Lock-outs (Proposal: Waive Section 1902(a)(8); Section 1902(a)(10)) TOPS and ASCO do not support waiver policies that have the potential to restrict or otherwise hinder access to Medicaid for individuals with a cancer diagnosis or who are at increased risk of cancer. The proposed 12-month re-enrollment lockout upon incidence of fraud would result in disruptions in care, unanticipated treatment delays, and is likely to lead to delays in screening for patients at an increased cancer risk. When patients are no longer able to access screening or other preventative care, they may (knowingly or not) delay seeking treatment until their disease is at an advanced stage. Such delays are linked to worse cancer care outcomes. Allowing TennCare patients to have continued access to early detection, screening, and care would more likely improve that patient’s health outcomes and decrease the cost burden of treating that patient overall. Restrictive Formulary (Proposal: Waive Section 1902(a)(54), insofar as it incorporates Section 1927) The proposal to implement a restrictive formulary with as few as a single drug per therapeutic class comes as a significant concern for continued access and potential health outcomes for TennCare cancer patients. It hinders guaranteed access to new and innovative drug therapies as well as undermines a physician’s ability to prescribe the most appropriate drug for a patient’s condition. Prescription drugs have different indications, different mechanisms of action, and different side effects, depending on the diagnosis and comorbidities of an individual patient. Restricting TennCare’s drug benefits to such a tightly restricted formulary would limit the ability of providers to make the best medical decisions for the care of their patients. Patients suffering from chronic, lifethreatening conditions need a guarantee of access to the appropriate prescription drugs critical to treating their disease. Provider Reimbursement Changes Under Block Grants (Proposal: Operate a managed care program that does not comply with the requirements of 42 CFR Part 438.) Medicaid reimbursements should be sufficient to ensure that Medicaid patients can have access to quality cancer care. The proposal’s inclusion of a transition from traditional Medicaid to a block grant approach that exempts the state from CMS’ reimbursement rate requirements for Medicaid managed care has the potential to leave already struggling practices and providers that accept TennCare at greater disadvantage. We are wary of what this could mean for access and network adequacy in a largely rural state, such as Tennessee. TennCare should institute network adequacy standards that are appropriate for ensuring that enrollees who are cancer patients or cancer survivors are able to access high quality cancer care in a timely fashion. Recognizing that states need flexibility to establish standards that are specific to the needs of their populations (even diverse populations within their states), TOPS and ASCO could support these network adequacy standards if they promote access based on specific patient needs, availability of care and providers, and appropriate utilization of services. Targeting Benefits to Certain Populations (Proposal: Section 1902(a)(10)(B)) TOPS and ASCO oppose the inclusion of state waivers for essential health benefit coverage and are therefore concerned by Demonstration Amendment 42’s proposal to remove the requirement of comparability and vary benefits packages. As cancer care providers, we know the critical importance of screening and preventative services for all patients. These coverage losses may lead to individuals with cancer being diagnosed later or not at all, negatively impacting lives and driving up costs to the health care system. Cancer patients represent a special population that should be largely exempt from regulations intended to restrict access or limit therapy options, in recognition of the unique nature of the disease, its treatment, and its potentially life-long aftereffects. Should Demonstration Amendment 42 move forward, we urge you to factor the needs of this specialized patient population into the design of TennCare’s benefits packages. TOPS and ASCO welcome the opportunity to be a resource for you. For a more detailed understanding of our policy recommendations on this issue, we invite you to read the ASCO Position Statement: Addressing Medicaid Waivers & Their Impact on Cancer Care and the ASCO Policy Statement: Medicaid Reform. Please contact Allison Rollins at allison.rollins@asco.org or Dr. Jack Erter at jerter@tnonc.com if you have any questions or if we can be of assistance. Sincerely, Jack W. Erter, III, MD President Tennessee Oncology Practice Society Howard “Skip” Burris, MD, FASCO President American Society of Clinical Oncology Jonathan Reeve From: Sent: To: Subject: Attachments: Tracey Doering Monday, October 14, 2019 5:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] block grants blockgrant (1).docx   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To whom it may concern:    Our council has met and has attached our response to the block grant proposal. We will send this to Governor Lee  also.  Thanks.      ‐‐   Tracey Doering, MD, FACP  Governor American College of Physicians‐TN Chapter  UTHSC/STH Internal Medicine  316 22nd Avenue North  Nashville, TN 37203  office 615‐284‐2155  cell 615‐347‐9643  email:  tracey.doering@gmail.com  1 Dear Governor Lee, TENNESSEE COUNCIL OF THE AMERICAN COLLEGE OF PHYSICIANS RESPONSE TO PROPOSED TENNCARE BLOCK  GRANT BY GOVERNOR LEE   The American College of Physicians has a long and consistent position of supporting universal access to quality  medical care for all people. At the Tennessee ACP Council meeting of October 10, 2019, the Federal block grant  for Tenncare proposed last month by Governor Lee was evaluated.  We cannot support this proposal in its present  form because:  It would allow authorities to change the covered core services that Tenncare would provide, and to limit optional  benefits, without requesting Federal approval, and without a public comment period.  Such changes might include  restricting home health care, hospice care, transplant services; or even such core services as the number of  hospital days or emergency room visits for a particular diagnosis or a particular time period.    It would eliminate Federal standards for Medicaid managed care plans, including allowing plans to provide limited  networks of physicians and other providers, and thereby limit access to care.   In an effort to save money, the present proposal would further limit an already sparse Tenncare formulary, by  limiting the covered medications to one drug per therapeutic drug class.  And there is no indication that the time‐ consuming prior approval process for uncovered pharmaceuticals would be improved.    The stated objective of Medicaid is to provide healthcare coverage to low income residents; and so, it is  disappointing to see that the proposal does not increase the number of patients covered by Tenncare.  It does not  expand Tenncare eligibility to any of the 200,000 low income adults whose income is too high for Medicaid and  too low to qualify for tax credits.    We also have real concerns about the lack of Federal oversight, which potentially increases the risk of fraud and  abuse within the program.  We urge that standard Federal oversight be put back into the proposal.  As physicians our greatest concern is the health and safety of our patients.  For the last 20 years when the health  of the citizens of our state has been measured against other states, we have consistently fallen into the lowest  quartile. As recently as this month (October 1) an article in the Journal of the American Medical Association  (JAMA. 2019;322(13):1253‐1254) confirmed that expansion of Medicaid improved health outcomes.   Unfortunately, we see little in the present proposal to improve health outcomes. We would encourage a clear  commitment that any savings that occur should the block grant proposal be accepted specifically be earmarked to  expand services to currently uninsured Tennesseans since evidence clearly supports this improves health  outcomes. Further, we urge the governor to reach out to physician organizations across the state for further input  since as frontline providers of care we, as physicians, hear directly from our patients the barriers they face  accessing care.  Respectfully submitted,     Tracey E. Doering, MD, FACP  Governor, TN Chapter of the American College of Physicians    cell:  615‐347‐9643  email:  tracey.doering@gmail.com  Jonathan Reeve From: Sent: To: Subject: Attachments: Beckmann, Tricia A. Friday, October 18, 2019 2:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Letter for TennCare II Demonstration: Amendment 42 MTAC Comment Letter re Amdt 42_TennCare II Demonstration_FINAL.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please see the Medical Transportation Access Coalition’s comment letter to the proposed Amendment 42.  Happy to  discuss and we appreciate your consideration.    Thank you!      Tricia A. Beckmann, J.D.  Director ‐ Faegre Baker Daniels Consulting  tricia.beckmann@FaegreBD.com    Download vCard  D: +1 202 312 7009   F: +1 202 312 7460    Faegre Baker Daniels LLP  1050 K Street NW   Suite 400   Washington, DC 20001, USA    This message and any attachments are for the sole use of the intended recipient(s) and may contain confidential and/or  privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended  recipient, please contact the sender by reply email and destroy all copies of the original message and any attachments.  Thank you.    1 October 18, 2019 Gabe Roberts, Deputy Commissioner Department of TennCare Sent via electronic mail to public.notice.tenncare@tn.gov Re: Amendment 42 (Block Grant) to TennCare II Demonstration Dear Mr. Roberts: This letter is in response to Tennessee’s proposed amendment (Amendment 42) to transform the financing structure of the TennCare II demonstration. The Medical Transportation Access Coalition (MTAC) (www.mtaccoalition.org) was formed in 2017 to educate federal and state policymakers and other stakeholders about the benefits of medical transportation and the need for policies that support continued access to these services. The coalition’s founding and allied members include a diverse set of transportation brokers and providers, managed care organizations and trade associations, and patient advocacy groups. The NEMT benefit in Tennessee is a critical, often life-sustaining, benefit for a diverse population of Medicaid beneficiaries in the state. This is borne out by the following data from Southeastrans and Tennessee Carriers, two MTAC members which operate as non-emergency medical transportation (NEMT) brokers for managed care organizations (MCOs) in the state: • Total trips to medically necessary care: 2,031,045 (2016); 1,842,094 (2017); 1,756,458 (2018) • About 5-6 percent of total beneficiaries in Tennessee qualify for and use the benefit and represent a broad swath of beneficiaries. According to Tennessee Carriers, roughly 15 percent of Medicaid NEMT riders in Tennessee are children (i.e., under 21 years of age), 33 percent are disabled adults, and 22 percent are seniors. • The most common trip destination is for behavioral and mental health (25-30 percent) followed by dialysis (20-26 percent), specialists (14-19 percent), and primary care (7-8 percent) As explained in further detail below, we specifically request that Tennessee confirm the state’s commitment to retain the NEMT benefit in its current amount, duration, and scope for the duration of the demonstration and any renewals or amendments thereof. We ask the state to include this commitment in documentation related to Amendment 42, in a similar way as other TennCare program features and benefits have been carved out of this demonstration. 1 Introduction The Amendment 42 proposal would cap Tennessee’s federal Medicaid funding for children, low-income parents, and people with disabilities, based on the state’s projected costs of serving these populations without the waiver. While not the main focus of this comment letter, we join others in sharing concerns regarding the proposed federal financing structure for two main reasons: (1) the Social Security Act Section 1115 does not appear to permit a state to waive Section 1903 concerning financing; and (2) the proposal does not articulate how it is likely to assist in promoting the objectives of Medicaid. Request to Implement Benefit Cuts without Advance Federal Review and Approval We also comment on the state’s request to implement benefit cuts without advance federal approval. The block grant proposal leaves Tennessee exposed if per-person TennCare costs grow substantially faster than expected, as could occur in a public health crisis (e.g., illicit drug epidemic, contagious disease outbreak, environmental or “natural” disaster), or due to innovations in medical treatment, not all of which can be addressed by implementing a closed formulary.1 This structure could incentivize Tennessee to reduce enrollment or make cuts to mandatory and optional benefits. The application notes the waiver plan fully protects current eligibility rules and benefits. We commend the state for asserting that there would be “no reductions in who is eligible for or what benefits are currently provided in TennCare” and that “it is not its intent under this proposal to reduce covered benefits for members below their current levels.” This is encouraging, as it presumably means the state does not intend to eliminate the mandatory NEMT benefit which must be provided for all those who qualify.2 We also applaud the state in seeking ways to invest in the health of TennCare enrollees, not just their healthcare. We are hopeful that this will mean expansion of transportation to destinations that are reasonably related to improving an individual’s health, along with other interventions to address social determinants of health.3 1 For example, the facility or provider costs to deliver innovative biologics, drug delivery devices, or specialty drugs are substantial and likely to put increased pressure on states in the years ahead. 2 See 42 C.F.R. 431.53. 3 To this end, Tennessee may wish to consider North Carolina’s Healthy Opportunities pilots, which specifically allow for reimbursement for plans to supplement mandatory NEMT with related supports such as non-medical transportation to social services to support community engagement, payment for public transportation, credits for cost-effective private transportation, and educational assistance in gaining access to public transportation. North Carolina Department of Health and Human Services, “North Carolina’s Healthy Opportunities Pilots: Draft Pilot Service Definitions, Pricing Methodology, and Pricing Inputs, July 15, 2019, available at: https://files.nc.gov/ncdhhs/documents/Public-Feedback-Pilot-Service-Definitions-and-Pricing-Inputs-FULLPACKAGE-FINAL.pdf 2 However, Tennessee also seeks to limit the “amount, duration, and scope” of core benefits that TennCare is required to provide, and to limit or eliminate optional benefits, without requesting approval from the federal government or providing an opportunity for public comment. We find this requested flexibility to be concerning. With respect to NEMT, the state gained federal flexibility by carving in NEMT to MCOs to allow them to manage the benefit as appropriate (such as through brokers). We ask that Tennessee amend the application to confirm that the state, using this requested block grant authority, will not eliminate the NEMT benefit in its current form, including eligible populations, and the benefit’s amount, duration, and scope. Amendment Should Include Additional Details for Meaningful Stakeholder Input By the very nature of the block grant, Tennessee seeks new authority to spend its federal dollars as it deems appropriate which raises stakeholder questions concerning potential benefit package changes, whether additions or reductions. To improve the clarity of the application, we recommend TennCare include a definitive list of which benefits could be targeted for “amount, duration, and scope” modifications using this block grant authority. Section 1115 regulations require the state’s public notice process to be sufficient to ensure a “meaningful level” of public input. One aspect of this “meaningful level” standard is the application must include a “comprehensive description of the demonstration application or extension,” including (1) “the proposed health care delivery system and the eligibility requirements, benefit coverage and cost sharing (premiums, co-payments, and deductibles) required of individuals that will be impacted by the demonstration, and how such provisions vary from the State's current program features,” and (2) “an estimate of the expected increase or decrease in annual enrollment, and in annual aggregate expenditures, including historic enrollment or budgetary data, if applicable.” 45 CFR 431.408(a)(1)(i) We request that Tennessee work to ensure that these elements of the application are addressed or resolved for purposes of receiving meaningful public input and eventual consideration by the federal government. The NEMT Benefit in Tennessee Saves Money in the Long Run Generally, Tennessee and other states cover a specific NEMT trip to a specific individual when certain conditions are met. NEMT is a critical benefit that is only utilized by those with no other means of transportation. Conditions for coverage include: • The beneficiary is eligible for Medicaid • For the trip to be covered, the medical service is eligible for Medicaid coverage and medically necessary • The beneficiary has no other means of getting to and from the medical service • The NEMT trip is authorized in advance • The NEMT trip is to the nearest qualified medical provider 3 • The NEMT trip is the lowest cost available transportation mode that is appropriate for the member Accordingly, NEMT is preserved for a small minority (5-6 percent in Tennessee) of the most vulnerable Medicaid enrollees. In addition, according to data from MTAC member LogistiCare, a broker operating in 32 states and providing 49,000,000 rides in 2018, roughly one-fourth of NEMT rides is provided through lower-cost alternatives to sedans, such as mass transit, mileage reimbursement, and rideshare. Further, using Medicaid claims and clinical guidelines, an MTAC-commissioned study examined whether NEMT, by increasing treatment adherence, saves money for Medicaid programs for three chronic conditions (dialysis, SUD, and diabetic wound care). The study found per 30,000 Medicaid members (10,000 with each condition), Medicaid savings per month is $40,040,304.4 This study affirms previous studies which model savings delivered by NEMT.5 Ultimately, a state uses well-managed NEMT as a tool for containing Medicaid spend, which aligns with Tennessee’s goals in seeking its additional waiver authorities, thus reinforcing the value of NEMT. This is why, we believe, it is appropriate to explicitly preserve NEMT as the state shapes its final waiver submission. We appreciate your thoughtful consideration of this letter as part of the administrative record, including the cited resources hyperlinked or otherwise referenced throughout. If you have questions, please contact tricia.beckmann@faegrebd.com. Sincerely, Tricia Beckmann, JD Director, Faegre Baker Daniels Consulting Advisor to Medical Transportation Access Coalition 4 See summary of beneficiary survey data below for more information, including methodology and margin of error. Available at: https://mtaccoalition.org/study-reveals-non-emergency-medical-transportation-nemt-is-extremelycost-effective-and-life-saving-to-medicaid-program/. 5 A report prepared for the Arkansas Health Reform Task Force concluded if access to NEMT services saved only one hospitalization in 100 trips, the return on investment (ROI) would be 10 to 1. Available at: https://www.stephengroupinc.com/images/engagements/Final-Report-Volume-II.pdf. Another study conducted by Florida State University found NEMT’s ROI factor to be 11 to 1. J. Cronin, Florida Transportation Disadvantaged Programs Return on Investment Study, Florida State University and Marking Institute (2008). Available at: https://ctd.fdot.gov/docs/AboutUsDocs/roi_final_report_0308.pdf. 4 Jonathan Reeve From: Sent: To: Subject: Attachments: Jim Schmidt Thursday, October 17, 2019 5:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] UHS Public Comment Letter on Block Grant Application UHS Block Grant Comment Letter 10.17.19.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please find the attached public comment letter from UHS of TN.  The letter outlines the comments from UHS' Behavioral  Health facilities across the state.      Thank you,  Jim    Jim Schmidt  President, Schmidt Government Solutions LLC  511 Union Street, Suite 710  Nashville, TN  37219  Office (615) 248‐3621  1 October 18, 2020 Mr. Gabe Roberts, Director Bureau of TennCare 310 Great Circle Drive Nashville, TN 37243 Dear Director Roberts: On behalf of UHS of Tennessee, we would like to submit the following comments on the state’s proposed waiver amendment relative to a block grant funding mechanism. UHS operates 10 facilities including psychiatric inpatient hospitals, inpatient and outpatient substance use treatment centers, and residential treatment centers for adolescents and youth across Tennessee. Our facilities care for a large number of TennCare enrollees with mental health and often co-occurring substance use needs so we would offer the following considerations as you prepare the final application document. We applaud the Bureau and the Administration for creating a unique proposal that would allow the state to have additional flexibility in operations and hopefully provide additional financial resources from the federal government to improve the health of Tennesseans. We understand that the commitment of the Bureau leadership is that current populations eligible for TennCare and the current services provided by the program will go unchanged. UHS believes that is an important commitment to the enrollees and providers in the program assuming CMS grants its approval to the state for relief from some of the current regulatory approvals required for programmatic changes. UHS would recommend that there is a process in place for continued public comment and meaningful input on future programmatic changes that could impact the services covered by TennCare. Providers and enrollees will benefit by being able to clearly communicate concerns and suggestions prior to implementation of significant changes. There should be a defined process for that input included in the draft application. The goal of the waiver application is that the state will continue its good stewardship of the public dollars spent on healthcare for TennCare’s enrollees and if the continued “savings” under the maximum federal dollars historically available to the state are achieved, then the state will receive half of that allotment for increased health programs and services for Tennessee. This investment would be very much welcomed, especially in additional mental health and substance use services and overall public awareness of these conditions. However, how those savings are achieved in a managed care system can be of concern and we would hope that the protections put in place over the years to maintain provider rates, enrollee and provider appeals mechanisms, limitations on denials of service and other patient and provider protections are continued. This is especially true relative to the laws and regulations around mental health parity in the coverage of mental health services and we would ask the state to make sure those are maintained. Finally, the waiver envisions the state requesting a significant change in the pharmacy coverage for enrollees in the program through implementation of a closed formulary and the ability of TennCare to not cover new-to-market innovator medications until significant evidence shows their efficacy. In the populations that our facilities serve, it is often the case that multiple medications within a therapeutic class must be tried before finding the appropriate medication for the specific patient. TennCare has always maintained appeals processes, an auto-exemption list for certain medications and a robust pharmacy program for its enrollees due to the important part that medication access and adherence plays in treating those with mental illness. We would encourage a full analysis of the impact of this potential change to providers and patients and would hope that there would be an outline of the appeals process to ensure patients have appropriate access to the medications they need to treat their condition without significant burden to providers. We thank you for the opportunity to submit these comments for consideration as Tennessee moves forward with its proposal to CMS. UHS welcomes the chance to continue the dialogue around this innovative proposal to hopefully increase both the funding of public health and potentially increase coverage of services and individuals on the program. Sincerely, Tim Smith CEO, Cedar Grove Treatment Center (Murfreesboro) Lisa Smith CEO, Compass Intervention Center (Memphis) Dr. Mark Lasko CEO, Hermitage Hall (Nashville) Joy Golden CEO, Lakeside Behavioral Health System (Memphis) Ernest Hickman CEO, McDowell Center for Children (Dyersburg) Eric Dunkerly CEO, Mountain Youth Academy (Mountain City) Tom Hennessey CEO, Natchez Trace Youth Academy (Waverly) Kelly Jessamy CEO, Oak Plains Academy (Ashland City) James Miller CEO, Rolling Hills (Franklin) Matt Feehery CEO, Foundations Recovery Network (Brentwood) Sally Lawes CEO, The Oaks at La Paloma (Memphis) Jonathan Reeve From: Sent: To: Cc: Subject: Attachments: Lauren J. Pearcy on behalf of Wanda Willis Monday, October 14, 2019 4:02 PM PUBLICE NOTICE TENNCARE Wanda Willis; Lauren J. Pearcy Comment from TN Council on Developmental Disabilities_Amendment 42 CDD Public Comment on Amendment 42 Block Grant.pdf Director Roberts: Attached are public comments on behalf of the Tennessee Council on Developmental Disabilities. Councils are established by federal law to exist in every state and territory, working to improve policies and practices that affect people with the most lifelong, significant disabilities. Our Tennessee Council members are appointed by the Governor, representing the diversity of the state across geographic location, type of disability, age, race and background. Each of the members has a personal connection to disability. We appreciate your careful consideration of this perspective. Thank you to your team for traveling across the state to hear comments and for meeting with our team to answer our questions. We greatly value the partnership between TennCare and the Council. Wanda Willis Lauren Pearcy Director of Public Policy Tennessee Council on Developmental Disabilities Davy Crockett Tower, First Floor 500 James Robertson Pkwy, Nashville, TN 37243 p. 615-741-5019 lauren.j.pearcy@tn.gov www.tn.gov/cdd www.facebook.com/TNCouncilonDD   1 STATE OF TENNESSEE COUNCIL on DEVELOPMENTAL DISABILITIES DAVY CROCKETT TOWER, FIRST FLOOR 500 JAMES ROBERTSON PARKWAY NASHVILLE, TENNESSEE 37243-0228 PHONE 615-532-6615 FAX 615-532-6964 October 14, 2019 Gabe Roberts Director, Division of TennCare 310 Great Circle Road Nashville, TN 37243 Re: Public Comment for Amendment 42: Block Grant Proposal Dear Director Roberts: On behalf of the Tennessee Council on Developmental Disabilities, please accept our public comments for Amendment 42, the request for a block grant to fund parts of TennCare. After carefully reviewing the proposal and consulting with our Council members, who are citizens from across the state with a direct connection to disability, we would like to recommend the following:    A plan for establishing checks and balances governing decisions about the program over time, which are currently provided by federal negotiations and oversight. For example: the appeals processes; changes to the amount, duration and scope of services; and regulations about provider network adequacy. A plan for assuring transparency to the public, both inviting and considering public comment when changes are made to the program. This process is currently required by federal regulations. Assurances that new limits to prescription drug coverage would be waived for people with rare conditions, behavioral health diagnoses, and disabilities. These populations often rely on specific choices among drugs within a classification and on “off label” drugs – both of which would be excluded from coverage under Amendment 42. A fundamental concern for the Council is that by ending the current, open-ended federal match, Tennessee will experience reduced funding over time for all Medicaid services, but particularly for the long-term services and supports component of the Medicaid program, which are the most expensive Medicaid services1. These services and costs for people with developmental disabilities are unlike “regular” Medicaid services: they are lifelong, they are 1 https://www.kff.org/report-section/medicaid-financing-the-basics-issue-brief/ Figure 6 specialized, and they are virtually not available outside of Medicaid. National estimates indicate that states only reach one quarter of people who need these services2. Essentially, without the open-ended federal match to fund long-term services and supports programs, we are concerned about the risk to Tennesseans with developmental disabilities in the future, even as the proposal includes an overall federal funding increase in the short-term. The Council deeply appreciates our partnership and ongoing communication with the Division of TennCare. Please do not hesitate to contact me for follow up discussion. Sincerely, Wanda Willis Executive Director wanda.wilis@tn.gov 2 https://aaidd.org/docs/default-source/National-Goals/supporting-families-of-people-with-idd.pdf Jonathan Reeve From: Sent: To: Subject: Attachments: Amanda Newell Friday, October 18, 2019 1:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Tennessee Hospital Association - Comments on Amendment 42 THA Comments Amendment 42 Block Grant Final.pdf   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good afternoon,    Please find the comments from the Tennessee Hospital Association attached.  We appreciate the opportunity to provide  our thoughts.     If you have any questions, please feel to call or email.     Thank you,  Amanda        Amanda Newell VP, Financial Policy 5201 Virginia Way Brentwood, TN 37027 P: 615.401.7441 anewell@tha.com www.tha.com     1 October 18, 2019 Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 RE: TennCare II Demonstration, Amendment 42 – Block Grant Request Dear Director Roberts: The Tennessee Hospital Association (THA), on behalf of its more than 140 member hospitals and health systems, appreciates the opportunity to comment on the proposed Amendment 42 to the TennCare II Demonstration. THA believes the overall structure of the block grant request does not put the state’s Medicaid program at risk and provides significant flexibilities that would offer several benefits to enrollees and providers. THA does seek more information and clarification on how the shared savings will be spent, the new flexibilities, protections for provider rates, and requests a future public comment opportunity if an agreement is reached. Following are our specific comments related to each of these topics. Shared Savings TennCare is a well-run, cost-effective program that has provided the federal government significant savings compared to the cost of a traditional fee-for-service Medicaid program in Tennessee. Unfortunately, the state has not been rewarded for its efforts and now is requesting to share in those savings under the block grant proposal. Allowing the state and federal governments to equally share in the federal share of any unspent block grant dollars would provide a considerable amount of additional funding into the program for providing enhanced coverage, higher provider reimbursement or funding for innovative projects. Similar to TennCare generating savings but not receiving recognition, many of the providers in Tennessee have implemented cost-saving programs that did not result in any shared savings from payers. For example, many of our facilities are building separate psychiatric emergency areas where patients who present having a psychiatric episode have a safe area to decompress, away from the ever-distracting and over-stimulating emergency department (ED). Our members build these departments and create other programs because they understand how beneficial they will be to their patients. While these initiatives improve the quality of patient care, the benefit of such improvements accrue totally to the program. If a portion of the shared savings generated from the block grant could be 5 2 0 1 V i rg i n i a W a y B r e n t w o o d , T e n n e s s e e 3 7 0 2 7 6 1 5 . 2 5 6 . 8 2 4 0 w ww . t h a . c o m Director Roberts Amendment 42 – Block Grant Page 2 of 6 distributed to reward providers for improving care or implementing cost-saving efficiencies, our members would be able to invest more resources into providing care and more pioneering solutions. New State Flexibilities Use of Block Grant Dollars The state seeks authority to spend block grant dollars on items and services not currently eligible for federal matching dollars or not otherwise covered under TennCare. The state provides examples, such as providing funding for medically necessary services for members in Institutions for Mental Diseases (IMDs) or addressing social determinants that have a direct impact on members’ health. THA understands these examples are representative of the state’s desire to expand services such as beyond the current limitation of 15 days per month for inpatient services to adult enrollees provided in IMDs. However, since it is not stated as such and they have only provided a few examples, we request a commitment from the state to work with providers to design new funded opportunities that include hospital-based quality programs and create innovations that improve care or reduce costs for TennCare enrollees. THA supports the request for more flexibility and understands the impact providing additional funding could have on services or programs beyond what currently is allotted. Tennessee hospitals are addressing social determinates in their communities and have been going above and beyond to provide better care, such as ONE Health, a program spearheaded by Regional One Health in Memphis that is addressing socioeconomic needs of the hospital’s uninsured. Addressing issues “upstream,” or those issues that might lead to poor health, can help mitigate serious illnesses and lower costs for the patients and healthcare system. THA believes this new flexibility would allow providers to be recognized for these contributions and allow for better health outcomes for the state. While THA and its members recognize the benefits this flexibility would afford the state, the state should ensure this results in incremental funding to the program without diluting from core services or from provider reimbursement. We appreciate the state clearly stating that these block grant dollars will not be used for purposes other than healthcare such as tourism development, financial institution regulations or routine infrastructure maintenance, but we request that state officials develop additional limiting factors to ensure Medicaid dollars are going to providers of care and access to care for enrollees is not jeopardized. Commercial-Style Closed Drug Formulary Citing issues with prescription drug costs and lack of management tools due to federal restrictions, TennCare is requesting a closed formulary with at least one drug available per therapeutic class. TennCare believes this would allow the state to better negotiate agreements with manufacturers because of guaranteed volume, which ultimately would generate cost savings for the state and federal governments. In addition, the state is requesting to have the flexibility to exclude new drugs until market prices are consistent or the state determines there is sufficient data regarding the cost-effectiveness of the drug. Director Roberts Amendment 42 – Block Grant Page 3 of 6 THA understands the concern the state has regarding high prescription drug costs, but we believe these requests are too restrictive and could put patients at risk. A one-size-fits all approach to prescription drugs is concerning as drugs can have different effects on patients, and while a single drug might work for most, there will be patients for whom the drug is not effective. If a new drug has been proven to be clinically effective for its intended treatment, we disagree with the state that these drugs be excluded until they believe them to be cost-effective. The clinical benefits should be prioritized over cost for Tennesseans, and we believe the expertise of clinicians should be relied on to make the best decisions for patients. We urge TennCare to reconsider its request to be allowed to have only one drug in any therapeutic class and develop policies that do not put patients’ care at risk. Rural Healthcare Recognizing the issues facing our rural communities, the waiver amendment requests flexibility to invest block grant dollars to support rural health transformation efforts, such as assisting providers in adopting technologies like electronic consultation or telemedicine. TennCare also describes using block grant dollars to support the development and implementation of new payment and delivery models and investing in infrastructure to transform rural facilities into more community-appropriate models. THA appreciates TennCare prioritizing these challenges and valuing the role our rural providers have in the state by being willing to invest in them. Tennessee has the second highest number of hospital closures since 2010 in the nation, most of those occurring in rural communities. Maintaining a medical presence is extremely vital to the well-being of a rural community, not just relating to health but also its economy. We look forward to working with the state to advance these goals and also ask for more detail. As the state negotiates and creates these policies, we urge the state to consider the following questions: What processes would the state implement to distribute funds? What input would the rural provider community have regarding the investments considered for block grant dollars? How would these funds be used to support patient access to fullservice community hospitals in the state? Waiving the Comparability Requirement TennCare is requesting to waive the comparability requirement, which requires Medicaid programs to provide the same benefits in amount, duration and scope for all covered populations (with some exceptions). TennCare believes it can provide services to address the diversity of member needs and the levels of care each need in a more targeted way. Removing this requirement also could allow the state to conduct pilot programs to explore emerging therapies and treatments before rolling them out statewide or to other enrollee categories that currently are hindered due to onerous administrative requirements. THA agrees this could be very beneficial and allows for greater potential to expand services, but we ask TennCare to be more specific on how it intends to apply this flexibility and appreciate the commitment that current levels of benefits will not be reduced. Director Roberts Amendment 42 – Block Grant Page 4 of 6 Uncompensated Care Pools THA understands the request to waive approval from the Centers for Medicare & Medicaid Services (CMS) to make changes to the participation requirements and distribution methodology in the waiver’s uncompensated care pools and appreciates that the state aspires to cover more uncompensated care in hospitals. However, THA has concerns over how the state has characterized the fact that when hospitals make changes to improve quality and efficiency that also will reduce cost, they will receive lower reimbursement. The current example that implies hospitals prioritize reimbursement over patient care is incorrect. THA believes the Bureau’s intent was to make the point that providing the most appropriate care may result in reducing utilization that reduces hospital revenue and the Bureau hopes to be able to reward the hospitals. A change in pool methodology and/or the new shared savings could replace some of the lost revenue. THA asks that the Bureau choose another more appropriate example in the proposal. THA also requests that its members continue to be a valued resource to the state and be included in the development and review of any changes so unintended impacts can be identified and assessed. Penalizing Member Fraud TennCare is requesting to remove or suspend benefits up to 12 months for members who are convicted of TennCare fraud. The state will develop its own policies based on severity and will consider if alternative actions may be allowed in lieu of termination or suspension, such as seeking substance use disorder treatment or suspending only a portion of their benefits. THA supports TennCare addressing fraud but suspending any portion of benefits shifts the cost of care to hospitals who treat all patients regardless of insurance coverage. THA believes the second option is preferable if the issue can be addressed without the enrollee becoming uninsured. Pathways to Permanency In the waiver amendment, TennCare is asking CMS to approve the 1115 waiver on a permanent basis and only require amendments to the waiver to go through the approval process or approve the waiver with a more extended timeframe. Citing the long and resource-heavy process that occurred during the 2016 waiver renewal, TennCare believes that either of these requests would allow the state and federal governments to better use their resources on program implementation. THA agrees with TennCare that the waiver approval process requires a tremendous amount of resources but would caution against a permanent waiver. The current administration has a long-standing relationship with our members and is well-respected. However, the future is unknown, and we would not want the program to be restricted. Improving Administrative Efficiency Reducing administrative burdens for the state and federal governments is a repeated goal throughout Amendment 42 and a reason for requesting broad flexibility. TennCare believes if some of the federal regulations can be lifted, the state could more efficiently administer the Medicaid program and better serve its enrollees. The state is requesting flexibility to change enrollment processes, service delivery systems and program elements without CMS approval, should they want to make changes in the future. TennCare also is requesting to have part of 42 Director Roberts Amendment 42 – Block Grant Page 5 of 6 CFR 428 waived, which is related to CMS oversight of managed care programs. A few parts that TennCare enumerates are federal review and approval of contracts with managed care organizations (MCOs), how the state establishes capitation rates and the actuarial soundness of rates. The state acknowledges that this is not an exhaustive list of requirements they will be requesting to waive. THA understands and supports the removal of some administratively burdensome requirements as long as the state remains transparent and does not lose sight into the MCOs. There are many provisions within 42 CFR 428 that are not just administrative requirements but protections for network adequacy and provide federal oversight for the entire program. THA appreciates TennCare’s assurance to not cut the program and urges the state to not waive any protections regarding the actuarial soundness of capitated rates. These protections provide safeguards for the financial soundness of the program and help guarantee it is funded at an appropriate level. We also request that TennCare provide a more definitive list of the requirements it will be asking to waive so providers and stakeholders can ensure none are detrimental to patients. Unnecessary Approvals Another flexibility TennCare is requesting is the ability to determine the amount, duration and scope of covered benefits that “do not affect the overall sufficiency of the benefit.” The state mentions optional benefits and the scope of mandatory benefits already are within its authority to change, but CMS requires them to seek approval through submission of a state plan amendment. THA is opposed to any benefits cuts, even for optional services and sincerely appreciates TennCare’s commitment to not reduce benefits below current levels. THA requests the state define “sufficiency” so there is a clear understanding of what changes to amount, duration and scope the state can implement that would not require federal approval and what changes would continue to require federal approval. Appeals Process Although it is reasonable to assume the current appeals process still would be in place under a block grant, THA would be remiss to not seek clarification, especially considering our concerns around many of these new flexibilities. Ensuring patients still maintain the right for administrative review, especially if their drug is not included under the requested drug formulary, is extremely important. Provider Protections Another protection that should be included in the waiver amendment is for provider rates to ensure access to care is not impacted. Hospital reimbursement under TennCare managed care is the lowest third-party reimbursement in Tennessee, providing hospitals only 60 cents for every dollar they spend on Medicaid patients. Any further reduction to that would cause significant harm to already struggling hospitals, especially in rural or underserved areas. THA strongly urges TennCare to provide assurances in the waiver request that provider rates and reimbursement will be protected from future cuts. In addition, if services are expanded or Director Roberts Amendment 42 – Block Grant Page 6 of 6 if enrollment is increased, THA requests reciprocal increases in provider reimbursement to ensure adequate compensation for providing care. Negotiations and Public Review THA joins with several other stakeholders to request an additional opportunity to review and comment on a final proposal before a block grant is implemented, should any agreement between the state and CMS be made. The likelihood that significant changes will occur to this request is high, and we believe it will be in the state’s best interest to provide another public comment period. Conclusion THA appreciates the attention given by the TennCare staff to many of the concerns that stakeholders have regarding running a Medicaid program under a block grant. This consideration is largely reflected in the design of the program, and the state has provided several protections that we believe can benefit TennCare enrollees and the state. THA believes that the additional flexibility awarded to the state could allow for more innovative approaches to healthcare and reward providers for their commitment to their communities. THA values our partnership with the Bureau and appreciates any opportunity to be a resource through this process. Thank you for the opportunity to share our thoughts and comments on the proposed amendment. If you have any questions or concerns regarding our comments, please contact me at wlong@tha.com. Sincerely, Wendy Long, MD President and CEO Tennessee Hospital Association Jonathan Reeve From: Sent: To: Subject: mere1679@everyactioncustom.com on behalf of Meredith Kirkpatrick Tuesday, October 22, 2019 6:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a physician, and I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the  federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr Meredith Kirkpatrick  Johnson City, TN 37601  mere1679@yahoo.com  1 Jonathan Reeve From: Sent: To: Subject: bgmeeks@everyactioncustom.com on behalf of Blair and Douglas Meeks Tuesday, October 22, 2019 9:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicare Block Grants do not make sense. If the proposal goes forward there will be lLESS not more funds available for those who need it most. Block grants are not good for the health of Tennessee's children or the hospitals that serve them.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Blair and Douglas Meeks  501 Clear Spring Ct  Brentwood, TN 37027‐7650 bgmeeks@mac.com  2 Jonathan Reeve From: Sent: To: Subject: rmsblack@everyactioncustom.com on behalf of Rose Black Tuesday, October 22, 2019 11:38 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Rose Black  PO Box 344  Cookeville, TN 38503‐0344  rmsblack@gmail.com  3 Jonathan Reeve From: Sent: To: Subject: knoles@everyactioncustom.com on behalf of Katherine Noles Monday, October 21, 2019 9:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.       This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Healthcare should be considered a right, not a privilege. Ultimately, we are only as strong as our weakest link, and for  the overall health of our communities, it is crucial we provide adequate healthcare‐‐including PREVENTIVE screenings &  care‐‐ for all.     Sincerely,  Katherine Noles  142 Pine St S  Bruceton, TN 38317‐2709  knoles@wraptn.org  4 Jonathan Reeve From: Sent: To: Subject: hebintn@everyactioncustom.com on behalf of Harry Bryant Sunday, October 20, 2019 10:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Harry Bryant  936 Taylor Hill Rd  Dandridge, TN 37725‐5361 hebintn@gmail.com  5 Jonathan Reeve From: Sent: To: Subject: storyteller81501@everyactioncustom.com on behalf of Jackie Myers Sunday, October 20, 2019 2:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Jackie Myers  5285 Red Rd  Sparta, TN 38583‐7723  storyteller81501@gmail.com  6 Jonathan Reeve From: Sent: To: Subject: storyteller81501@everyactioncustom.com on behalf of Jackie Myers Sunday, October 20, 2019 2:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Please do not do the block grant. We have a baby in our family that was provided care thru TennCare. I only found out about this on the 19th of October.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Jackie Myers  5285 Red Rd  Sparta, TN 38583‐7723  storyteller81501@gmail.com  7 Jonathan Reeve From: Sent: To: Subject: carl.h.johnson@everyactioncustom.com on behalf of Carl Johnson Sunday, October 20, 2019 3:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Don't give Tennessee a Block Grant   Dear Gabe Roberts,    I am writing to oppose giving Tennessee a Medicaid block grant. As a citizen of Tennessee for 30+ years, I can attest that  the current state of TennCare is poor. It was created in the 1990’s and initially was great. But years of mismanagement  and lack of funding has left it in a mess. In the last few years, it has seen a 20% percent increase in the number of  uninsured children. Of the children who lost coverage, TennCare does not even know how many children were actually  ineligible and how many lost their coverage due to administrative problems (such as, TennCare had no functioning  computer system from 2014 to the recent present).    Our previous governor tried to persuade the state legislature to expand Medicaid and cover more underinsured  Tennesseans, but the state legislature did not pass it for pig‐headed political reasons. Because of this lack of health  insurance, rural hospitals have closed in Tennessee, leaving many counties without immediate access to an emergency  room. Giving Tennessee a block grant for Medicaid will not stop these hospital closures.  In fact, it may increase hospital  closures and initiate nursing home closures.    Listed in the block grant proposal is an item to restrict patients to one medication only; I have medical training, and  there are few serious illnesses that can be adequately treated with just one medication. Duhhh . . . .    This Block Grant proposal is obviously written to release Tennessee from federal oversight and accountability. Please do  not give Tennessee a Block Grant. Tennessee is so busy counting pennies that it cannot see all the dollars it has wasted  on hospital closures and poor medical outcomes from the lack of healthcare availability.    Sincerely,  Dr. Carl Johnson  4412 Milesdale Ct  Nashville, TN 37204‐4127 carl.h.johnson@vanderbilt.edu  8 Jonathan Reeve From: Sent: To: Subject: scompton45@everyactioncustom.com on behalf of Susan Compton Sunday, October 20, 2019 8:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Susan Compton  Greeneville, TN 37745  scompton45@yahoo.com  9 Jonathan Reeve From: Sent: To: Subject: mark_hutchins2010@everyactioncustom.com on behalf of Mark Hutchins Sunday, October 20, 2019 10:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Mark Hutchins  Kingsport, TN 37660  mark_hutchins2010@yahoo.com  10 Jonathan Reeve From: Sent: To: Subject: julianfotre@everyactioncustom.com on behalf of Julian Fitre Saturday, October 19, 2019 4:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr Julian Fitre  Nashville, TN 37212  julianfotre@comcast.net  11 Jonathan Reeve From: Sent: To: Subject: durantjodee@everyactioncustom.com on behalf of Jodee Berry Saturday, October 19, 2019 9:52 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jodee Berry  Elizabethton, TN 37643  durantjodee@gmail.com  12 Jonathan Reeve From: Sent: To: Subject: onebluelove55@everyactioncustom.com on behalf of Tera Wragg Saturday, October 19, 2019 1:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  My son is profoundly developmentally delayed, is blind, non verbal, epileptic, has CP, scoleosis, has had 13 surgeries and  he's 11. His monthly medicines total close to $5k.....equipment for him since he cannot move his body AT ALL‐range  from $300 to $9k. We could never afford that. Especially now that I had to quit my job because our hidden nanny  camera caught the LPN covered by Tenncare smacking him several times in the face! (WSMV channel 4 news‐‐ 10/18/2019 aired‐). Please rethink this!!!!!  Sincerely,  Tera Wragg    Sincerely,  Tera Wragg  Sparta, TN 38583  onebluelove55@gmail.com  13 Jonathan Reeve From: Sent: To: Subject: sarah.holman@everyactioncustom.com on behalf of Sarah Holma Friday, October 18, 2019 8:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sarah Holma  Blountville, TN 37617  sarah.holman@gmail.com  14 Jonathan Reeve From: Sent: To: Subject: gvmtflks@everyactioncustom.com on behalf of maureen organ Friday, October 18, 2019 8:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] let's improve medicaid, not "make a deal"   Dear Gabe Roberts,    I am opposed to the proposal to converting federal funding for TennCare into a “block grant.” I have previously  submitted comments but a presentation at the Spouthern Festival of Books prompts me to write again.    Dr Johathan Metzyl, Vanderbilt professsor, shared some insights that are published in his book "Dying of Whiteness;How  the Politics of Racial Resentment is Killing America's Heartland."      One of the major data collection efforts listed is measuring a wide variety health indicators for Kentucky compared to  Tennessee since the Medicaid expansion was offered through the Affordable Care Act.    Kentucky nearly immediately signed up for the program and Tennessee still has not.  It is no surprise that Kentucky  citizens experienced a significant improvement in nearly every indicator while the people of Tennessee showed a  marked decline in those values.    We are chasing spending less money on Medicaid while our population considers to sicken.  This could not be more  wrong.    Thank you for accepting these comments.        Sincerely,  maureen organ  5041 Grady Ln  Whites Creek, TN 37189‐5102 gvmtflks@gmail.com  15 Jonathan Reeve From: Sent: To: Subject: alainastout@everyactioncustom.com on behalf of Alaina Stout Friday, October 18, 2019 8:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Alaina Stout  123 Dearmond Pl Erwin Erwin, TN 37650‐4132 alainastout@yahoo.com  16 Jonathan Reeve From: Sent: To: Subject: barnebi@everyactioncustom.com on behalf of Billie Barnette Friday, October 18, 2019 8:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Loss of medical assistance   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Before her death my aunt was totally dependent on TennCare, Medicaid, and Medicare.  There were times when  TennCare did not provide coverage or Bill's were not paid.  This forced her to have to squeeze more money from her  monthly checks. How can we expect these people to get a handle on dispensing monies to protect our seniors and  others needing this help.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Billie Barnette  337 Piercy St  Blountville, TN 37617‐6304 barnebi@comcast.net  17 Jonathan Reeve From: Sent: To: Subject: brittadurkee@everyactioncustom.com on behalf of Britta Durkee Friday, October 18, 2019 8:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Britta Durkee  Nashville, TN 37211  brittadurkee@hotmail.com  18 Jonathan Reeve From: Sent: To: Subject: sandyshiveley@everyactioncustom.com on behalf of Sandra Shiveley Friday, October 18, 2019 8:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am writing to express my opposition to radically change TennCare through a block grant.   Given the nature of our  current legislature, our population could suffer if decisions were made to cut services to our most vulnerable citizens,  including our children.       The TennCare program we now have should be improved rather than subject to the cuts that new authority could  permit.   Our rural hospitals are closing now, and this proposal may accelerate this travesty for our state    I implore you to reject my state’s application for a block grant.    Respectfully,    Sandra   Shiveley      Sincerely,  Mrs. Sandra Shiveley  Brentwood, TN 37027  sandyshiveley@sprynet.com  19 Jonathan Reeve From: Sent: To: Subject: plastybill@everyactioncustom.com on behalf of Willilam Schneider Friday, October 18, 2019 8:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the change of a block grant to replace Medicaid   Dear Gabe Roberts,    I am a retired physician and had many Medicaid patients over the years. I am very concerned about the possibility of  making Medicaid a block grant. Many of these patients are the very ones who most need quality healthcare. I feel that  changing the fundamentals of this program, with what seems to be an effort to save money, may well cost access to  basic health needs for many vulnerable Tennesseans.    I oppose the effort to make this program a block grant as Tennessee needs to continue to improve its delivery of  healthcare not diminish it.     William Schneider, MD    Sincerely,  Dr Willilam Schneider  706 Westborough Rd  Knoxville, TN 37909‐2133 plastybill@comcast.net  20 Jonathan Reeve From: Sent: To: Subject: aprillord2929@everyactioncustom.com on behalf of April Lord Friday, October 18, 2019 8:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  April Lord  41 Weatherly Dr  Lebanon, TN 37087‐4103  aprillord2929@gmail.com  21 Jonathan Reeve From: Sent: To: Subject: jorgesallesd@everyactioncustom.com on behalf of Jorge Salles Díaz Friday, October 18, 2019 8:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jorge Salles Díaz  1626 16th Ave S Apt B3 Nashville, TN 37212‐2925 jorgesallesd@gmail.com  22 Jonathan Reeve From: Sent: To: Subject: bjmbarnett@everyactioncustom.com on behalf of Briley Barnett Friday, October 18, 2019 8:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Briley Barnett  Old Hickory, TN 37138  bjmbarnett@bellsouth.net  23 Jonathan Reeve From: Sent: To: Subject: jordanstewartdortch@everyactioncustom.com on behalf of Jordan Malone Friday, October 18, 2019 8:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.        I am a recipient of Tenncare. I would not have had a healthy pregnancy nor been able to give birth in a hospital  without Tenncare. I was part of the vulnerable population who would be severely mistreated without this program. I  oppose the changes proposed and I hope that the state doesn't leave a shameful mark on its caretaking of Tennesseans  by making the change to a block grant system.     Sincerely,  Jordan Malone  29 Plus Park Blvd  Nashville, TN 37217‐1029 jordanstewartdortch@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: kayjoy3@everyactioncustom.com on behalf of Kaylee Brown Friday, October 18, 2019 8:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kaylee Brown  510 Old Hickory Blvd  Nashville, TN 37209‐5164 kayjoy3@gmail.com  25 Jonathan Reeve From: Sent: To: Subject: melissaingle@everyactioncustom.com on behalf of Melissa Rogers Friday, October 18, 2019 9:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Melissa Rogers    Sincerely,  Melissa Rogers  Bluff City, TN 37618  melissaingle@gmail.com  1 Jonathan Reeve From: Sent: To: Subject: hscswad@everyactioncustom.com on behalf of Harold Waddle Friday, October 18, 2019 8:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant will hurt the poort Proposal   Dear Gabe Roberts,    I am strongly opposed to the proposal to radically change Tennessee’s Republican plot to end the Medicaid partnership  with the federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Harold Waddle  Oak Ridge, TN 37830  hscswad@hotmail.com  2 Jonathan Reeve From: Sent: To: Subject: Cynthia Polewach Friday, October 18, 2019 9:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Cynthia Polewach   135 Chahyga Way  Loudon, TN 37774   3 Jonathan Reeve From: Sent: To: Subject: Louisatp@everyactioncustom.com on behalf of Martha Louisa Tucker Friday, October 18, 2019 9:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am writing to express my opposition to the proposal to radically change Tennessee’s Medicaid partnership with the  federal government by converting federal funding for TennCare into a “block grant.” As the wife of a longtime Pediatric  Cardiologist, I have seen and witnessed the heartbreaking choices families with children with health challenges face.   What had been limited coverage offerings for those in need have been slashed even further, and too many of our most  vulnerable Tennesseans have been cut from their needed medical care because of lack of funding.  The "block grant" will  cut even more from the needed care.  This is unacceptable.       Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Martha Louisa Tucker  8321 Georgetown Bay Dr  Ooltewah, TN 37363‐5985 Louisatp@aol.com  4 Jonathan Reeve From: Sent: To: Subject: daniel4sign@everyactioncustom.com on behalf of Beth Harrell Friday, October 18, 2019 10:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I do not trust that our elected officials, in particular our Tennessee state representatives and senators, have the interests of the most vulnerable at heart. They have proven it over and over again by not expanding medicare/Tenncare to the  working poor.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.        Sincerely,  Beth Harrell  2417 Shacklett Rd  Murfreesboro, TN 37129‐1982 daniel4sign@gmail.com  5 Jonathan Reeve From: Sent: To: Subject: nfohara@everyactioncustom.com on behalf of Nancy OHara Friday, October 18, 2019 10:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these  vulnerable populations. The state could eliminate or restrict services like physical therapy, hospice, and transplant  coverage without normal federal oversight – and arbitrarily limit who gets them. The proposal could also cut back on  core health care services like hospital care, without federal approval or public notice, and exclude coverage of the most  effective prescription drugs.     TennCare needs more accountability, not less. To listen to the legislators and governor making this proposal, IT IS  ABOUT SAVING $1 mil FOR THE STATE, RATHER THAN IMPROVING SERVICES AND EXPANDING  SERVICES To include the  200,000 Tennesseans who have no health care coverage.  Our politicians should not be allowed to make changes to the  Medicaid program or vary from federal standards, in place to protect patients.    This waiver goes against the goals and purpose of the Medicaid program. We respectfully urge you not to go forward  with this harmful proposal.    Sincerely,  Nancy OHara  417 Moss Creek Ct  Nashville, TN 37221‐2828 nfohara@comcast.net  6 Jonathan Reeve From: Sent: To: Subject: pegintn@everyactioncustom.com on behalf of Peggy Watson Friday, October 18, 2019 10:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Peggy Watson  1407 Moorgate Dr  Knoxville, TN 37922‐6033 pegintn@aol.com  7 Jonathan Reeve From: Sent: To: Subject: wm.scott.willis@everyactioncustom.com on behalf of William Willis Friday, October 18, 2019 10:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rev. William Willis  Murfreesboro, TN 37129  wm.scott.willis@gmail.com  8 Jonathan Reeve From: Sent: To: Subject: vickie.w.willis@everyactioncustom.com on behalf of Vickie Willis Friday, October 18, 2019 10:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a person whose faith leads me to advocate for the common good. As a result, I am opposed to the proposal to  radically change Tennessee’s Medicaid partnership with the federal government by converting federal funding for  TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable  Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Vickie Willis  3218 Windsor Green Dr  Murfreesboro, TN 37129‐5848 vickie.w.willis@gmail.com  9 Jonathan Reeve From: Sent: To: Subject: bglazejohnson@everyactioncustom.com on behalf of Beverly Johnson Friday, October 18, 2019 10:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Beverly Johnson  Madison, TN 37115  bglazejohnson@yahoo.com  10 Jonathan Reeve From: Sent: To: Subject: peggysue54@everyactioncustom.com on behalf of Peggy Wilson Friday, October 18, 2019 10:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Peggy Wilson  1015 Pullen Rd  Sevierville, TN 37862‐6064 peggysue54@att.net  11 Jonathan Reeve From: Sent: To: Subject: mmd78@everyactioncustom.com on behalf of Melanie Dover Friday, October 18, 2019 3:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Melanie Dover  Franklin, TN 37069  mmd78@bellsouth.net  12 Jonathan Reeve From: Sent: To: Subject: camerontucker.parks@everyactioncustom.com on behalf of Cameron Tucker Friday, October 18, 2019 4:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Cameron Tucker  Hendersonville, TN 37075  camerontucker.parks@gmail.com  13 Jonathan Reeve From: Sent: To: Subject: tnjustice@everyactioncustom.com on behalf of Helen Puckett Friday, October 18, 2019 2:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Helen Puckett  1422 Brewers Chapel Rd  Sneedville, TN 37869‐6859 tnjustice@puckettscomputers.com  14 Jonathan Reeve From: Sent: To: Subject: KARIS622@everyactioncustom.com on behalf of Kimberly risner Friday, October 18, 2019 4:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kimberly risner  863  Antioch, TN 37013  KARIS622@GMAIL.COM  15 Jonathan Reeve From: Sent: To: Subject: Janine Johnson Friday, October 18, 2019 4:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Janine Johnson   8017 Cedar Lake Cove  Memphis, TN 38138   16 Jonathan Reeve From: Sent: To: Subject: ms.brnsuga1@everyactioncustom.com on behalf of Yolonda Williams Friday, October 18, 2019 4:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Yolonda Williams  3728 Harvest Rdg  Clarksville, TN 37040‐5468 ms.brnsuga1@gmail.com  17 Jonathan Reeve From: Sent: To: Subject: carleenclaybaker@everyactioncustom.com on behalf of Carleen Claybaker Friday, October 18, 2019 4:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Bottom line, the correct action that should have been taken long ago is to expand Medicaid.  It is completely  unacceptable that our representatives have not taken the option, and Tennesseans have and continue to suffer and die,  needlessly.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Carleen Claybaker  212 W Holston Ave  Johnson City, TN 37604‐5524 carleenclaybaker@aol.com  18 Jonathan Reeve From: Sent: To: Subject: chrishlyons@everyactioncustom.com on behalf of Chris Lyons Friday, October 18, 2019 4:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.    On a personal level, having worked with individuals who need but have been denied medical services by TennCare as  part of its already‐too‐harsh attempts to cut costs, having had several family members with serious disabilities who  required these types of services, and having family that lives in the rural areas that will be harshly affected by this  proposal (including through additional hospital closings and the like), I am profoundly saddened by this proposal that  appears to do nothing more than putting Tennesseans' health at risk in order to pursue a political agenda.  Rather than  focusing on this type of proposal that would cut resources from those who most need them, we should be focusing on  expanding TennCare using the funds already available to our state through the Affordable Care Act.    I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Chris Lyons  Nashville, TN 37206  chrishlyons@hotmail.com  19 Jonathan Reeve From: Sent: To: Subject: btccampbell@everyactioncustom.com on behalf of Berdelle Campbell Friday, October 18, 2019 4:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal        This proposal is so harmful ! so Backward ! accomplishes NOTHING good for Tenn and its citizens.   We, the state, is  getting famous for doing the wrong thing, the BAD things, the "unthinking" things. We are damaging Tennesseans  health, even causing untold early deaths.    Don`t be guilty of lining Tennessee up as the very first state to make the Unthinkable move  of CHOOSING to have a  Block grant.  It`s time, past time, to think of your people First.    PLEASE make us proud of you, our leaders, and  give us cause for HOPE. Not more of the hopeless feelings you  continually pass our way.    NO BLOCK GRANT FOR TENNESSEE.    Sincerely,  Berdelle Campbell  1217 5th Ave N  Nashville, TN 37208‐2723 btccampbell@comcast.net  20 Jonathan Reeve From: Sent: To: Subject: trainisloud@everyactioncustom.com on behalf of Joel Alex Friday, October 18, 2019 4:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a social worker that serves families in Davidson County. I am opposed to the proposal to radically change  Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into a “block  grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans. I can guarantee  you that those who need TennCare the most will be put in harm.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. As a front line social worker in Davidson County I can tell you that  individuals particularly those most vulnerable (adults with severe health concerns and children... Children are often left  without insurance due to policy changes in TennCare. From my position TennCare needs complete overhaul, but  certainly not less accountability. The state should not be allowed to make changes to the Medicaid program without  federal oversight or eliminate federal standards, which are in place for the protection of patients. Without such  guardrails, the state could return to the days when managed care contractors failed to provide care to patients and  providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital health coverage  for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joel Alex  4502 Old Hickory Blvd  Nashville, TN 37218‐4035 trainisloud@gmail.com  21 Jonathan Reeve From: Sent: To: Subject: artgolfo@everyactioncustom.com on behalf of Steve Mitchell Friday, October 18, 2019 4:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Steve Mitchell  4500 Heath Rd  Nashville, TN 37221‐6603  artgolfo@comcast.net  22 Jonathan Reeve From: Sent: To: Subject: newmoonlmt@everyactioncustom.com on behalf of Tina McMillan Friday, October 18, 2019 4:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Tina McMillan  7600 Old Maynardville Pike  Knoxville, TN 37938‐3731 newmoonlmt@gmail.com  23 Jonathan Reeve From: Sent: To: Subject: Nathan Jones Friday, October 18, 2019 5:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Nathan Jones   105 Southburn Dr  Hendersonville, TN 37075   24 Jonathan Reeve From: Sent: To: Subject: SARA SMITH Friday, October 18, 2019 5:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   SARA SMITH   1125 Sharpe Ave  Nashville, TN 37206   25 Jonathan Reeve From: Sent: To: Subject: kellywilliams.tn@everyactioncustom.com on behalf of Kelly Williams Friday, October 18, 2019 5:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Keep Tennessee Healthy   Dear Gabe Roberts,    I live in rural Tennessee. Medicaid is vital to the working poor in this area.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kelly Williams  400 Hickory Grove Rd  Huntland, TN 37345‐5504 kellywilliams.tn@gmail.com  26 Jonathan Reeve From: Sent: To: Subject: miriamharmatz@everyactioncustom.com on behalf of Miriam Harmatz Friday, October 18, 2019 5:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to  convert federal funding for TennCare into a “block grant.” This proposal would  harm  the health of low income vulnerable Tennesseans.     I grew up in Tennessee and have had friends who relied on TennCare for critical life saving services. I was proud of  Tennessee's early TennCare program and how it helped save my friends' lives when they got cancer and MS as young  adults. I was saddened to see the cuts to TennCare several years ago and am appalled to now see this shortsighted  proposal.     The proposal goes against the objectives of Medicaid Act and will no  doubt be subject  to legal challenge thus taking up  limited resources on the part of both the state and advocates.     Sincerely,    Miriam Harmatz  (former resident of Oak Ridge, Tennessee)      Sincerely,  Miriam Harmatz  3793 Irvington Ave  Miami, FL 33133‐6105 miriamharmatz@gmail.com  27 Jonathan Reeve From: Sent: To: Subject: charris@everyactioncustom.com on behalf of Clifton Harris Friday, October 18, 2019 5:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Clifton Harris  50 Vantage Way Ste 201 Nashville, TN 37228‐1500 charris@urbanleagueofmidtn.org  28 Jonathan Reeve From: Sent: To: Subject: lewislane15@everyactioncustom.com on behalf of Jimetta Lewis Friday, October 18, 2019 6:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This truly destroys access to medical needs of the many  who need it. You should have expanded Medicaid when you had the chance!  Rural hospitals could have stayed open!    This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Jimetta Lewis  155 Kingsdown Dr  Crossville, TN 38558‐8663 lewislane15@rocketmail.com  29 Jonathan Reeve From: Sent: To: Subject: deborah.holman@everyactioncustom.com on behalf of Deborah Holman Friday, October 18, 2019 6:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,                              I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Deborah Holman  180 Gravel Top Rd  Blountville, TN 37617‐3928 deborah.holman@gmail.com  30 Jonathan Reeve From: Sent: To: Subject: kbowers@everyactioncustom.com on behalf of Kay Bowers Friday, October 18, 2019 6:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I'm opposed to the medicaid block grant proposal. It is too vague and opaque at best.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kay Bowers  4033 Albert Dr  Nashville, TN 37204‐4009 kbowers@nlcdc.com  31 Jonathan Reeve From: Sent: To: Subject: tcostonis@everyactioncustom.com on behalf of Theresa Costonis Friday, October 18, 2019 2:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Theresa Costonis  442 Bowling Ave  Nashville, TN 37205‐2524 tcostonis@yahoo.com  32 Jonathan Reeve From: Sent: To: Subject: deborah.holman@everyactioncustom.com on behalf of Deborah Holman Friday, October 18, 2019 6:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,              I have read your template and I agree with it. Now I would like to add some of my personal observations. My aunt had  tenncare before she died and I can truly say her death would have been much sooner with out the coverage. When it  appeared that she was to be cut from the roll she worried about how she would ever be able to get to the doctor's office  or get her medicine. It made her physically ill to think about it. That is an example of Tennessee controlling the tenncare   rolls. How much worse it would be if they actually controlled the funds allowed.  We have seen how well they do health  with giving us a medical monopoly here in our area. They do not even begin to do adequate oversight and this is only a  portion of the state. How could they cover the whole state? Please do give them the chance to ruin this also.        I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Deborah Holman  180 Gravel Top Rd  Blountville, TN 37617‐3928 deborah.holman@gmail.com  33 Jonathan Reeve From: Sent: To: Subject: merrilee2460@everyactioncustom.com on behalf of Terry Wineinger Friday, October 18, 2019 6:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Stop this nonsense. Everyone needs to have access to affordable high‐quality health care.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Terry Wineinger  1381 Drakes Creek Rd  Hendersonville, TN 37075‐8519 merrilee2460@gmail.com  34 Jonathan Reeve From: Sent: To: Subject: callj22@everyactioncustom.com on behalf of Jesse Call Friday, October 18, 2019 6:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. As the program coordinator for an emergency shelter for families experiencing  homelessness in Tennessee, I know this decision will cause harm to our residents that struggle with chronic illnesses.  Tennessee has routinely failed to protect those without homes and other vulnerable populations, and this is just the  latest way to try and scapegoat those with illnesses and often cannot work.  We need the backup of the federal government to ensure Tennessee does not harm its most vulnerable citizens.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Jesse Call  1208 Pennock Ave  Nashville, TN 37207‐5716 callj22@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: bessdinah@everyactioncustom.com on behalf of Dinah Bess Friday, October 18, 2019 6:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dinah Bess  223 Ewing Dr  Nashville, TN 37207‐2950  bessdinah@gmail.com  36 Jonathan Reeve From: Sent: To: Subject: Diane Gregory Friday, October 18, 2019 6:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Diane Gregory   115 Hiwassee Ln  Loudon, TN 37774   37 Jonathan Reeve From: Sent: To: Subject: Rachel Hopper Friday, October 18, 2019 7:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Rachel Hopper   135 Iron Gate Ln  Dickson, TN 37055   38 Jonathan Reeve From: Sent: To: Subject: cjhause@everyactioncustom.com on behalf of Catherine Hause Friday, October 18, 2019 7:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a retired teacher who often saw the devastating effects of inadequate healthcare on my students, I am opposed to  the proposal to radically change Tennessee’s Medicaid partnership with the federal government by converting federal  funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans most especially my former students & their parents.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  Sincerely,  Catherine Hause.    Sincerely,  Catherine Hause  5032 Nelson Dr  Franklin, TN 37064‐1772  cjhause@comcast.net  39 Jonathan Reeve From: Sent: To: Subject: tinamae32@everyactioncustom.com on behalf of Tina Meli Friday, October 18, 2019 7:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tina Meli  Murfreesboro, TN 37128  tinamae32@yahoo.com  40 Jonathan Reeve From: Sent: To: Subject: steve2carol@everyactioncustom.com on behalf of Carol Krauss Friday, October 18, 2019 7:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    The county that I call home, White Dounty, has a large percentage of people who depend on Tenn Care for their medical  care.  Many of them have conditions which require complex medical treatment.  Medical care by block grant will be  detrimental to their health.]    Sincerely,    Carol Krauss    Sincerely,  Carol Krauss  6714 Forest Village Way Day Knoxville, TN 37919‐1903 steve2carol@bellsouth.net  41 Jonathan Reeve From: Sent: To: Subject: dsbarnette@everyactioncustom.com on behalf of David Barnette Friday, October 18, 2019 7:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  David Barnette  Cleveland, TN 37312  dsbarnette@yahoo.com  42 Jonathan Reeve From: Sent: To: Subject: johnwatkins240@everyactioncustom.com on behalf of John Watkins Friday, October 18, 2019 7:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] We need Tenncare for my Grandaughter. We take care of her because her parents are on drugs.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  John Watkins  983 Kinsler Ave  Kingsport, TN 37665‐1913 johnwatkins240@yahoo.com  43 Jonathan Reeve From: Sent: To: Subject: malnrobs@everyactioncustom.com on behalf of Mallorie Hatcher Friday, October 18, 2019 7:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Hi my name is Mallorie Hatcher from Johnson City, Tennessee.  I work fulltime as an Occupational Therapist and my  husband Robert, who was my highschool sweetheart, works as a firefighter.   We are proud parents of 7 year old  daughter Londyn and a 5 year old son Nolan.  I am writing today to speak on behalf of my son Nolan and all children with  complex medical needs and disabilities.       Nolan started kindergarten this year.  He loves dirt bikes, music, vacuum cleaners and choo choo trains.  Nolan has a  microduplication on his 17th chromosome at the p arm of 13.1 to 13.2, it is classified as a rare chromosome disorder.  If  you saw him you would assume he is much younger than he is due to his slow growth.  Nolan has feeding difficulties  (requiring supplemental nutrition through his feeding tube), global learning delays, chiari malformation (requiring yearly  MRIs and possible nuerosurgery in future) and epilepsy (requiring daily medication).  He has multiple hospitalizations  and surgeries during his life.  He has more than a handful of specialty physicians and regular speech and occupational  therapy sessions in order to help him best thrive.       Tennessee has a history of being a low tax and underserved state. For instance my son Nolan , despite having complex  medical needs and disabilities, has never been eligible for any form of Medicaid in the state of Tennessee.  In fact our  state falls far under the national average in terms of coverage for individuals with disabilities.  Our family like many  others have been fully dependent on private employer insurance for my son’s care.  Medically necessary services like  therapy, specialized formulas and medical equipment are not covered.  This is in addition to already high deductible and  out of pocket expenses has put our family in significant medical debt.    This past year we had the opportunity to advocate at the state level to get a much needed Bill passed in our state.  We  all courageously came together and worked to get a medicaid waiver passed in Tennessee specific for children with  complex medical needs and disabilities.  I no longer felt alone and families like my own felt heard and supported.  We  felt like our leaders were beginning to understand the reality and shortcomings of our state when caring for a child with  complex medical needs and disabilities.  When learning of Amendment 42 to fund Medicaid through a Block Grant we  felt betrayed.  We are scared  once again, but we have hope that we are once again able to come to an understanding  that Medicaid is a life saving program (not an experiment) and that our children's lives matter.      My son has a genetic condition, he will not outgrow this. Reality is my son will one day grow up to be an adult with a  disability.  His life will depend on his access to life saving medical care to survive and thrive to his best potential. Access  to healthcare should be a human right, not a privilege. A price tag should not be put on any life.    My story only gives a small glimpse as to why this is a bad idea.  Allowing flexibility in a state that is already highly  underserved is a recipe for disaster and could result in rationing of care among its most vulnerable residents.     Bottom Line ‐‐‐‐ This is a harmful proposal that cannot be  fixed.   It goes against the goals and purpose of the Medicaid program. I respectfully urge you not to go forward with this  harmful proposal.    Sincerely,  44 Mallorie Hatcher  110 Shannon Ln  Johnson City, TN 37601‐1330 malnrobs@gmail.com  45 Jonathan Reeve From: Sent: To: Subject: maxiswell0713@everyactioncustom.com on behalf of francis maxwell Friday, October 18, 2019 7:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I have a close relative whose Son has seizures. She has had to use the services of TennCare for treatment of this condition. Many times her frustration with the bureaucracy of this organization has been expressed to me. Let's not make this w...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  francis maxwell  Heiskell, TN 37754  maxiswell0713@aol.com  46 Jonathan Reeve From: Sent: To: Subject: irrianna37@everyactioncustom.com on behalf of Jessica Kolling Wednesday, October 23, 2019 2:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jessica Kolling  3641 Memorial Blvd  Kingsport, TN 37664‐3422 irrianna37@gmail.com  47 Jonathan Reeve From: Sent: To: Subject: josephwinberry@everyactioncustom.com on behalf of Jossih Winberry Friday, October 18, 2019 11:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    The reality is that Medicare expansion is not political. It is about helping neighbors in need. Other states like Montana  have taken advantage of this opportunity; why should we allow Tennessee to lose this competitive edge?     Sincerely,  Jossih Winberry  Seymour, TN 37865  josephwinberry@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: Addison743@everyactioncustom.com on behalf of Brenda Barnett Friday, October 18, 2019 12:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Brenda Barnett  Mosheim, TN 37818  Addison743@gmail.com  49 Jonathan Reeve From: Sent: To: Subject: drstephenswann@everyactioncustom.com on behalf of Stephen Swann Friday, October 18, 2019 12:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Stephen Swann  Chattanooga, TN 37411  drstephenswann@gmail.com  50 Jonathan Reeve From: Sent: To: Subject: peggy55410@everyactioncustom.com on behalf of Peggy Duhamel Friday, October 18, 2019 12:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    In addition, I would like to add that the best way forward for the State of Tennessee is to participate in the Medicaid  expansion program.  We should look carefully at the states that have expanded Medicaid and recognize the great strides  they have made in both providing access to care for their residents and the positive financial and health outcomes that  have been documented.  It is foolhardy for the state of Tennessee to continue to lose out on the now billions of our tax  dollars that we could have been using to make care available, support our health care delivery systems and make our  state a better place for all.  The rural hospital closures are horrific to those communities and the loss of jobs associated  with the closures have had wide ranging impacts on those areas.  We need to move forward with the Medicaid  expansion and stop this alternate plan that could cost our state lives and have an overall negative impact for the people  of Tennessee.    Sincerely,  Ms. Peggy Duhamel  2104 Duntreath Mdws  Germantown, TN 38139‐3524 peggy55410@yahoo.com  51 Jonathan Reeve From: Sent: To: Subject: Addison743@everyactioncustom.com on behalf of Brenda Barnett Friday, October 18, 2019 12:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Brenda Barnett  Mosheim, TN 37818  Addison743@gmail.com  52 Jonathan Reeve From: Sent: To: Subject: jaehee.kim@everyactioncustom.com on behalf of Jaehee Kim Friday, October 18, 2019 11:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Dear Mr. Gabe Robert,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,   Jaehee Kim    Sincerely,  Jaehee Kim  Nashville, TN 37203  jaehee.kim@vanderbilt.edu  53 Jonathan Reeve From: Sent: To: Subject: crazyriver@everyactioncustom.com on behalf of Susan McCue Friday, October 18, 2019 12:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    For All the Stated Reasons Below I am Vehemently Opposed to this Hijacking of desperately needed MEDICAL CARE from  fellow Tennesseans....the most vulnerable.  This is a GOP swindle of TAXPAYER dollars ‐ diverting taxes into out‐dated,  out‐of‐touch GOP agenda driven directions and policies that are keeping one of the states with the most opportunities  into a wasteland of brokenness. As evidenced by our constantly terrible ratings in education, health, drug‐addiction,  incarceration, struggling & dying communities towns, suffering farmers, etc. etc. There is not one reason, based on facts,  studies. data & research, that supports this change as beneficial for TN residents.  Just TN GOP.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Susan McCue  Knoxville, TN 37912  crazyriver@mail.com  54 Jonathan Reeve From: Sent: To: Subject: eaholme@everyactioncustom.com on behalf of Emily Holmes Friday, October 18, 2019 12:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am writing because I am strongly opposed to the proposal to radically change Tennessee’s Medicaid partnership with  the federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.     I work with many economically disadvantaged students who rely on TennCare for their health care. Anything that  jeopardizes their health jeopardizes our entire community.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     We need federal oversight. We also need our rural hospitals, many of which have closed due to the failure of the state  to expand medicaid.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Emily Holmes  2276 Evelyn Ave  Memphis, TN 38104‐5528  eaholme@yahoo.com  55 Jonathan Reeve From: Sent: To: Subject: jenifermeeks@everyactioncustom.com on behalf of Jenifer Meeks Friday, October 18, 2019 12:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jenifer Meeks  211 Williford St  Memphis, TN 38112‐3223 jenifermeeks@yahoo.com  56 Jonathan Reeve From: Sent: To: Subject: prestonj@everyactioncustom.com on behalf of Preston Johnston Friday, October 18, 2019 12:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Preston Johnston  Nolensville, TN 37135  prestonj@princeton.edu  57 Jonathan Reeve From: Sent: To: Subject: chief37040@everyactioncustom.com on behalf of JOHN DEAN Friday, October 18, 2019 11:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.     There are Seniors and the Disabled that cannot live without TennCare. Those that favor Block Grant will be remembered  on Election Day.    Sincerely,  Mr. JOHN DEAN  566 Current Rd  Clarksville, TN 37040‐6190 chief37040@gmail.com  58 Jonathan Reeve From: Sent: To: Subject: matt.h.pitts@everyactioncustom.com on behalf of Matthew Pitts Friday, October 18, 2019 12:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the conversion of Tenncare into a block grant funded program. An aging population with chronic  illnesses will suffer when funding does not grow to meet the needs of our neighbors. The State will also be given too  much authority to choose what procedures and medications are covered. The State will be incentivized to further limit  enrollment and care with the proposed sharing of savings. This entire proposal is a way to create the “need” for future  cuts to a program that keeps our neighbors healthy.      Sincerely,  Matthew Pitts  Memphis, TN 38104  matt.h.pitts@gmail.com  59 Jonathan Reeve From: Sent: To: Subject: la.prisco1@everyactioncustom.com on behalf of Larry prisco Friday, October 18, 2019 12:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Larry prisco  1802 Shelby Ave  Nashville, TN 37206‐2152 la.prisco1@gmail.com  60 Jonathan Reeve From: Sent: To: Subject: Joel Allen Friday, October 18, 2019 1:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenn Care- Medicaid Block Grant proposal To allow US taxpayer funds to be given to lawmakers in any state in the form of "block grants" with no oversight,  particularly in TN, is a mistake. These policymakers can not be trusted to use funds fairly without federal oversight. It is  WRONG to use taxpayer money is any such manner.  Any Republican controlled legislature in any state has a track  record of overlooking the poorest among us in the name of fraud abuse and fiscal responsibility.  To deny people  healthcare, in particular the poorest and most vulnerable among us(‐children‐the elderly poor‐) is wrong. Prior history  among such Republican controlled state legislatures shows that these lawmakers are very willing to do so in the name of  controlling fraud and abuse of the system. There are numerous other ways to guard against abuse and fraud in such  systems other than the denial of benefits to the people who may need such assistance in earnest and have no other  means with which to receive it.    I say DENY "block grants" to these policymakers and keep the system, with oversight improvements in place, as it is.  There is a reason these "policymakers" wish to have block grants with no oversight  apparatus in place, and it is not to better serve those who are truly in need of healthcare assistance.     Chris Allen  NAMI Member and Tennessee Resident  61 Jonathan Reeve From: Sent: To: Subject: indigo@everyactioncustom.com on behalf of Nancy Hellsten Friday, October 18, 2019 12:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    PLEASE do not move to block grants. This will hurt so many in our state including my friends and family who rely on  federal Medicare in one way or another.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Nancy Hellsten  Knoxville, TN 37934  indigo@thehellstens.com  62 Jonathan Reeve From: Sent: To: Subject: jennifer.hout76@everyactioncustom.com on behalf of Jennifer Hout Friday, October 18, 2019 12:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jennifer Hout  7029 Meadow Ridge Cir  Nashville, TN 37221‐7911 jennifer.hout76@gmail.com  63 Jonathan Reeve From: Sent: To: Subject: deborah.lynn@everyactioncustom.com on behalf of Deborah Lynn Friday, October 18, 2019 1:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I am Opposing Medicaid Block Grant Proposal because   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Currently I serve as Chaplain in rural Tennessee.  Already I am seeing people with no way to pay for their treatment or  prescriptions as they have either been dropped by TennCare or not eligible.  Another particular person comes to mind as  his insurance stopped covering the diabetes medicine that works best for his particular body.  He is not doing as well  with the different medication.  I have many more stories to tell in just 18 months of employment in rural Tennessee.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    And it seems to me as if the legislature almost wants tens of thousands of people statewide to suffer and die needlessly.   What has caused you and your colleagues to propose such harsh and mean actions?      I urge you to not pass the Block Grant Proposal.      Sincerely,  Rev. Deborah Lynn  272 Clearlake Dr W  Nashville, TN 37217‐4546 deborah.lynn@ascension.org  64 Jonathan Reeve From: Sent: To: Subject: jbyassee@everyactioncustom.com on behalf of Jean Byassee Friday, October 18, 2019 1:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would release Tennessee from the carefully  thought out policies and regulations of Federal Medicaid guidelines and policies.  If Tennessee has seemed to have a  cost effective program, it is because it denies needed coverage to a large population of persons who need coverage, not  because it is very efficient  in provision of services as compared to similar programs in other states.  Other  methodologies should be tried in Tennessee.     I respectfully urge you not to go forward with this harmful proposal.      Jean L. Byassee    Sincerely,  Jean Byassee  3414 Benham Ave  Nashville, TN 37215‐1504 jbyassee@dvlawfirm.com  65 Jonathan Reeve From: Sent: To: Subject: apeant@everyactioncustom.com on behalf of April Cook Friday, October 18, 2019 1:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    /Users/apeant/Desktop/MEDICARE BLOCK GRANT OPPOSITION.docx    Sincerely,  Ms. April Cook  204 Laurel Ln  Lookout Mountain, TN 37350‐1315 apeant@att.net  66 Jonathan Reeve From: Sent: To: Subject: Turkeycraw@everyactioncustom.com on behalf of nancy Lambert Friday, October 18, 2019 1:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] You dont give a fox the keys to the henhouse and except him to treat the chickens fairly. This is just some more 'let's take control' of the lives of our community by the 'bought and paid for' governor and the corrupt Levine of Ballard Health.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. nancy Lambert  PO Box 5736  Kingsport, TN 37663‐0736  Turkeycraw@aol.com  67 Jonathan Reeve From: Sent: To: Subject: aminormail2@everyactioncustom.com on behalf of Angela Minor Friday, October 18, 2019 1:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    This is a decision which will leave our most vulnerable family, friends, and neighbors at risk!    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Angela Minor  1411 Star St SE  Cleveland, TN 37323‐4043 aminormail2@gmail.com  68 Jonathan Reeve From: Sent: To: Subject: cdowling123@everyactioncustom.com on behalf of Carrie Dowling Friday, October 18, 2019 1:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] edicaid Block Grant Proposal   Dear Gabe Roberts,    I am a family medicine physician and care for fragile senior citizens and disabled persons, many of whom are low  income. I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr Carrie Dowling  7140 Stage Rd  Memphis, TN 38133‐8955  cdowling123@hotmail.com  69 Jonathan Reeve From: Sent: To: Subject: chrisfortennessee@everyactioncustom.com on behalf of Chris Rowe Friday, October 18, 2019 1:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. My father is one such Tennesseean, and he has suffered enough. He's disabled,  and requires regular, expensive medical treatment. Treatment which would simply be cut off when block grant funding  ran out. That's not the solution.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Chris Rowe  PO Box 2258  Elizabethton, TN 37644‐2258 chrisfortennessee@gmail.com  70 Jonathan Reeve From: Sent: To: Subject: brynan54@everyactioncustom.com on behalf of Nancy Holland Friday, October 18, 2019 1:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal from Nancy Holland   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.        As a nurse for 26 years, I have seen how important it is for those patients who have enjoyed excellent health care and  MUCH better quality of life as a result of TennCare.  My daughter and her children relied on this coverage for a short  time after her husband left her; now she is back on her feet, but having this resource was invaluable. My husband and I  work with an inner city church where several of our at‐risk members are on TennCare. Their health issues seem  insurmountable, and our church helps them, but they would be lost without this coverage.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  Sincerely, Nancy Holland    Sincerely,  Nancy Holland  926 Spurling Dr  Hixson, TN 37343‐2426  brynan54@comcast.net  71 Jonathan Reeve From: Sent: To: Subject: kbierly527@everyactioncustom.com on behalf of Krista Turner Friday, October 18, 2019 1:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Krista Turner  Bon Aqua, TN 37025  kbierly527@gmail.com  72 Jonathan Reeve From: Sent: To: Subject: tdallgood@everyactioncustom.com on behalf of Teresa Allgood Friday, October 18, 2019 1:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    it is outrageous to think that our Governor has selected Alan Levine to give advice about what is best for Tennessee.  He  has already corrupted our Healthcare in East Tennessee and now  our Governor and elected officials are attempting to  eliminate services for the poor and disabled citizens of Tennessee.  I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Teresa Allgood  2128 Longreen Rd  Kingsport, TN 37660‐5055 tdallgood@charter.net  73 Jonathan Reeve From: Sent: To: Subject: andrewneilpfeffer@everyactioncustom.com on behalf of Andrew Pfeffer Friday, October 18, 2019 1:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Andrew Pfeffer  1101 Halcyon Ave  Nashville, TN 37204‐2529 andrewneilpfeffer@gmail.com  74 Jonathan Reeve From: Sent: To: Subject: pkoates@everyactioncustom.com on behalf of Paula Oates Friday, October 18, 2019 1:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a parent of an adult with a disability and an advocate. Please do not do this.  Our children and adults with a  disability do not deserve to lose more insurance benefits.  As our children become adults, there are fewer and fewer  physicians, who accept TennCare insurance.  With this shortage there is a long wait for appointments, especially new  patients.    Please remember that they are U.S. Citizens, who deserve to be cared for by qualified physicians and treated with  respect.        Sincerely,  Paula Oates  Memphis, TN 38119  pkoates@gmail.com  75 Jonathan Reeve From: Sent: To: Subject: Burnett4343@everyactioncustom.com on behalf of STEPHEN BURNETT Friday, October 18, 2019 1:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  STEPHEN BURNETT  157 Oak Hill Cir  Sewanee, TN 37375‐2026 Burnett4343@bellsouth.net  76 Jonathan Reeve From: Sent: To: Subject: merrilee2460@everyactioncustom.com on behalf of Terry Wineinger Friday, October 18, 2019 2:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Stop the Block Grant ‐ Now before Colossal Damage is Done to Tennesseans.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Terry Wineinger  1381 Drakes Creek Rd  Hendersonville, TN 37075‐8519 merrilee2460@gmail.com  77 Jonathan Reeve From: Sent: To: Subject: tmoran6359@everyactioncustom.com on behalf of Tonya Moran Friday, October 18, 2019 1:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tonya Moran  Athens, TN 37303  tmoran6359@gmail.com  78 Jonathan Reeve From: Sent: To: Subject: Burnett4343@everyactioncustom.com on behalf of STEPHEN BURNETT Friday, October 18, 2019 1:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  STEPHEN BURNETT  157 Oak Hill Cir  Sewanee, TN 37375‐2026 Burnett4343@bellsouth.net  79 Jonathan Reeve From: Sent: To: Subject: bard.avon1@everyactioncustom.com on behalf of Christine Mather Friday, October 18, 2019 2:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the Medicaid Block Grant Proposal because it will harm Tennesseans   Dear Gabe Roberts,    Dear Mr. Gabe Roberts,    Do not make Tennessee the first state in the nation to use block grants for Medicaid. This will cost Tennessee money  and hurt Tennesseans who rely on Medicaid funds for insurance and other essential life services.    TennCare is flexible NOW and has created good programs like ECF Choices. There is no reason to eliminate future  services for more flexibility.       I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     While there are some short‐term protections built into the plan, Tennessee's population will continue to grow. So in the  long‐term there will not be enough money for those who need help, since the amount will no longer be determined by  the need.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Christine Mather  Nashville, Tennessee    Sincerely,  Christine Mather  973 Davidson Dr  Nashville, TN 37205‐1041 bard.avon1@gmail.com  80 Jonathan Reeve From: Sent: To: Subject: guntergewalt@everyactioncustom.com on behalf of Gunther Gewalt Friday, October 18, 2019 2:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Gunther Gewalt  3836 Sunflower Ct  Morristown, TN 37814‐1614 guntergewalt@aol.com  81 Jonathan Reeve From: Sent: To: Subject: ldizzyjordan@everyactioncustom.com on behalf of Laurie Jordan Friday, October 18, 2019 2:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Laurie Jordan  409 Cottonwood Dr  Nashville, TN 37214‐3321 ldizzyjordan@aol.com  82 Jonathan Reeve From: Sent: To: Subject: hohumholler@everyactioncustom.com on behalf of Carol Forman Friday, October 18, 2019 2:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans.  I believe Tennessee should have expanded Medicaid under the  Affordable Care Act.  The block grant issue will only lead to more individuals without medical care.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Carol Forman  645 Fox Lake Ln  La Follette, TN 37766‐5986 hohumholler@gmail.com  83 Jonathan Reeve From: Sent: To: Subject: Ryne Chandler Friday, October 18, 2019 2:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Ryne Chandler   1419 Meridian St  Nashville, TN 37207   84 Jonathan Reeve From: Sent: To: Subject: charlow0501@everyactioncustom.com on behalf of Cheryl Harlow Friday, October 18, 2019 2:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Cheryl Harlow  1245 Kentucky Ave  Bristol, TN 37620‐4405 charlow0501@gmail.com  85 Jonathan Reeve From: Sent: To: Subject: mitzipearson19@everyactioncustom.com on behalf of Mitzi Pearson Friday, October 18, 2019 2:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mitzi Pearson  400 Neal Ln  Kingsport, TN 37660‐6238  mitzipearson19@gmail.com  86 Jonathan Reeve From: Sent: To: Subject: rrickardfnp52@everyactioncustom.com on behalf of Charles Rickard Friday, October 18, 2019 2:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Charles Rickard  81 Jr Jones Rd E  Humboldt, TN 38343‐8176 rrickardfnp52@gmail.com  87 Jonathan Reeve From: Sent: To: Subject: dileeca@everyactioncustom.com on behalf of Carol Lee Friday, October 18, 2019 2:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant proposalmment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal will harm the most vulnerable.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid and will make it harder for those  in extreme need to get the services they do need. The state could eliminate or restrict services like physical therapy,  hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The proposal  could also cut back on core health care services like hospital care, without federal approval or public notice, and exclude  coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.   It makes me think of the mess that the VA Administration got into in the past and it was the patients that suffered.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Carol Lee  111 Cove Rd  Cookeville, TN 38506‐6330  dileeca@yahoo.com  88 Jonathan Reeve From: Sent: To: Subject: lisawillson.lw@everyactioncustom.com on behalf of Lisa Willson Friday, October 18, 2019 2:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lisa Willson  155 Kelly Ln Apt 101 Lenoir City, TN 37771‐2090 lisawillson.lw@gmail.com  89 Jonathan Reeve From: Sent: To: Subject: sunflowerherbshoppe@everyactioncustom.com on behalf of Eveline Gewalt Friday, October 18, 2019 2:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, ESPECIALLY NICU babies who need very specialized care and a FLEXIBLE pharmacy  formulary.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Eveline Gewalt  1923 W Andrew Johnson Hwy  Morristown, TN 37814‐3740 sunflowerherbshoppe@musfiber.com  90 Jonathan Reeve From: Sent: To: Subject: Amanda Walker Friday, October 18, 2019 2:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Amanda Walker   6000 Frontier Ln  Nashville, TN 37211   91 Jonathan Reeve From: Sent: To: Subject: Duane Ylvisaker <1jetlag@gmail.com> Friday, October 18, 2019 2:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Duane Ylvisaker   116 Walosi Way  Loudon, TN 37774   92 Jonathan Reeve From: Sent: To: Subject: kristinholley23@everyactioncustom.com on behalf of Kristin Holley Friday, October 18, 2019 2:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kristin Holley  122 Baker Rd  Hohenwald, TN 38462‐5505  kristinholley23@gmail.com  93 Jonathan Reeve From: Sent: To: Subject: missaesdesjardins08@everyactioncustom.com on behalf of Missaes Desjardins Friday, October 18, 2019 2:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Missaes Desjardins  PO Box 60074  Nashville, TN 37206‐0074  missaesdesjardins08@hotmail.com  94 Jonathan Reeve From: Sent: To: Subject: cnd2day@everyactioncustom.com on behalf of Cynthia Lybrand Friday, October 18, 2019 2:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a disabled person, I am opposed to the changes in Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such protection, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud, abuse and threatens the availability of critical health  coverage for Tennesseans.     This waiver is flawed and cannot be fixed without 22 million people losing health coverage over the next 10 years, with  15 million of them from the Medicaid rolls.     Cutting taxes for  corporations and the wealthy, thereby harming children, people with disabilities, pregnant women,   seniors, low‐income parents, is cruel and inhumane.    I respectfully urge you not to go forward with this harmful proposal ‐ we are depending on your help.    Sincerely,  Cynthia Lybrand  2518 Plymouth Rd Apt 13 Johnson City, TN 37601‐8944 cnd2day@gmail.com  95 Jonathan Reeve From: Sent: To: Subject: wallace2home@everyactioncustom.com on behalf of Pam Wallace Friday, October 18, 2019 2:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.                                                                                                                                                                                                       Although I  do not personally know anyone receiving TennCare, nor do I have work dealings with TennCare, I do know this is a big  mistake for Tennessee.  To expect the State of Tennessee to provide required oversight is beyond reckless.  Please look  into how the TN Dept. of Health and TN Atty. General are not adequately overseeing the COPA for Ballad Health in NE  TN, which has already been shown NOT to be to the public's advantage.  I can happily share emails I received from Mr.  Jeff Ockerman and Mr. Larry Fitzgerald that include them contradicting themselves and admitting to misinforming the  public while trying to defend elimination of certain healthcare services our community needs.    And, speaking of the high risks of fraud and abuse re. this proposal, something about this legislation sounds very similar  to another healthcare scheme perpetrated upon our community by one Mr. Alan Levine.  Please look into his work  history (in both the public health and private healthcare spheres) and start to follow the fraud and abuse in other states.  Please do not let Tennessee be further added to that list.      This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Pam Wallace  511 Whisperwood Dr  Greeneville, TN 37743‐6645 wallace2home@yahoo.com  96 Jonathan Reeve From: Sent: To: Subject: carolinemann@everyactioncustom.com on behalf of Caroline Mann Friday, October 18, 2019 2:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I find this proposal baffling in many respects, but one is its ominous outlook for older Tennesseans who are lured here  by the promise of low income taxes. With rural hospitals closing, and civic boosters no longer able to entice retirees to  Tennessee by assuring them of the availability of medical care, why would the state choose to hamstring itself by  limiting the amount of money it can access to support the retirees it hopes to attract? This proposal shows an alarming  willingness to achieve cost savings by harming those people who can least afford to lose medical services ‐ especially  since the state is incented to cut costs by the promise of a refund if spending falls to a below‐average level.    Expand Medicaid in Tennessee. Don't constrain it.    Sincerely,  Caroline Mann  5520 Westover Dr  Knoxville, TN 37919‐4136 carolinemann@usa.net  97 Jonathan Reeve From: Sent: To: Subject: donnell.king@everyactioncustom.com on behalf of Donnell King Friday, October 18, 2019 2:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    My daughter is profoundly disabled. While I have regular insurance, it cannot pay for the nursing that keeps my  daughter alive because it is considered "chronic care." We rely on TennCare to provide that. Without it, she would be  dead within a year, and likely I would too, because my wife is also disabled. It is simply impossible for me to care for  Hannah 24 hours a day, without even considering how in the world I am supposed to do that and still maintain a job.  And yet, even with the current system, I have had to fight tooth and nail to keep her covered. If this Block Grant goes  through, you will likely be passing our death warrants at worst. At best, we will have to move to another state, which is  practically impossible in our circumstances.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Donnell King  Alcoa, TN 37701  donnell.king@gmail.com  98 Jonathan Reeve From: Sent: To: Subject: marlajap1959@everyactioncustom.com on behalf of Marla Goldman Friday, October 18, 2019 3:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marla Goldman  2006 Knapton Ct  Spring Hill, TN 37174‐6132 marlajap1959@gmail.com  99 Jonathan Reeve From: Sent: To: Subject: ellenvkirk@everyactioncustom.com on behalf of Ellen Kirk Friday, October 18, 2019 2:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ellen Kirk  334 Stillcreek Dr  Franklin, TN 37064‐6155 ellenvkirk@gmail.com  100 Jonathan Reeve From: Sent: To: Subject: katieanntwiggs@everyactioncustom.com on behalf of Katie Twiggs Friday, October 18, 2019 3:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] No To The Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, older individuals and other vulnerable  Americans get vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives  Tennessee new authority to cut services for these vulnerable populations. The state could eliminate or restrict services  like physical therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets  them. The proposal could also cut back on core health care services like hospital care, without federal approval or public  notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     I work with older Tennesseean's who are trying to navigate the very complicated process of applying for TennCare's  Long‐Term Supports and Services program.  These individuals are often in desperate need of care in the home or care in  the nursing home. They are good people who have worked their whole life and deserve to grow older in a safe and  comfortable environment with dignity.  The application process for the CHOICES program is already complicated and  over‐burdensome to applicants.  I have worked with countless CHOICES eligible individuals who have been improperly  denied simply because of bureaucratic red tape and lack of transparency from the state. Because of this poor track  record and the consequential suffering I have witnessed first hand, I believe less federal oversight will put more people  at risk of being improperly denied and/or being cut off from coverage and life‐saving care.      This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Katie Twiggs  1608 23rd Ave N  Nashville, TN 37208‐2308 katieanntwiggs@gmail.com  101 Jonathan Reeve From: Sent: To: Subject: mr.davidstein@everyactioncustom.com on behalf of David Stein Friday, October 18, 2019 2:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  David Stein  Germantown, TN 38139  mr.davidstein@gmail.com  1 Jonathan Reeve From: Sent: To: Subject: donjoyner@everyactioncustom.com on behalf of Don Joyner Friday, October 18, 2019 3:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    No! No! A thousand times No! I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with  the federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Don Joyner  8125 Devens Dr  Brentwood, TN 37027‐7130 donjoyner@icloud.com  2 Jonathan Reeve From: Sent: To: Subject: Cindy Porter, 5519 Hill Court Friday, October 18, 2019 3:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid The block grant is a bad idea.  TN will lose out on federal funds and the citizens will lose out on health care.    Cindy Porter  3 Jonathan Reeve From: Sent: To: Subject: kate_tooley@everyactioncustom.com on behalf of Kate Tooley Friday, October 18, 2019 2:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kate Tooley  564 Tara Oaks Cv  Collierville, TN 38017‐1682 kate_tooley@hotmail.com  4 Jonathan Reeve From: Sent: To: Subject: drm0964@everyactioncustom.com on behalf of Gerald Stone Friday, October 18, 2019 3:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    The block grant idea the the Republican party has pushed in Tennessee, is liked by only the political power brokers of  the party. This has to be the single most selfish, near‐sighted, destructive idea that has been perpetrated upon the   citizens of Tennessee.    It will not benefit any of the citizens that depend on Tenncare the most. It has been a failure at all of the public  presentations in Tennessee, no one here wants it, except the Republican elite. We here want you to leave Medicaid  alone.    Sincerely,    Gerald Stone         Sincerely,  Mr. Gerald Stone  51 Hillcrest Villa Rd  Manchester, TN 37355‐3864 drm0964@charter.net  5 Jonathan Reeve From: Sent: To: Subject: lrittle@everyactioncustom.com on behalf of Loretta Rittle Friday, October 18, 2019 3:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would only further jeopardize healthcare  coverage for vulnerable Tennesseans.     Tennessee already has the most uncovered children and the most hospital closings in the country.  The inadequacies of  the Tenncare computer system has already eliminated care for critically needed services to thousands of children.   This  proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these  vulnerable disabled, elderly, and poverty populations. The state could eliminate or restrict services like physical therapy,  hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The proposal  could also cut back on core health care services like hospital care, without federal approval or public notice, and exclude  coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Loretta Rittle  11 Burton Hills Blvd Apt 252 Nashville, TN 37215‐6141 lrittle@yahoo.com  6 Jonathan Reeve From: Sent: To: Subject: jonilaney@everyactioncustom.com on behalf of Joan Laney Friday, October 18, 2019 3:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joan Laney  2547 Mcadoo Ave  Memphis, TN 38112‐3819  jonilaney@gmail.com  7 Jonathan Reeve From: Sent: To: Subject: tommi.stephenson@everyactioncustom.com on behalf of Tommi Stephenson Friday, October 18, 2019 3:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I think that block grants will be the equivalent of death panels. I think that our state does too little for kids with disability  already and that making us fight over a block of funding is cruel and inhumane.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Tommi Stephenson  Nashville, TN 37218  tommi.stephenson@comcast.net  8 Jonathan Reeve From: Sent: To: Subject: tnsenate32candidate@everyactioncustom.com on behalf of ERIC COLEMAN Friday, October 18, 2019 3:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. ERIC COLEMAN  6125 Christina Wood Dr  Memphis, TN 38135‐6174 tnsenate32candidate@ericcoleman.org  9 Jonathan Reeve From: Sent: To: Subject: lindsaykharte@everyactioncustom.com on behalf of Lindsay Harte Friday, October 18, 2019 3:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lindsay Harte  Nashville, TN 37206  lindsaykharte@gmail.com  10 Jonathan Reeve From: Sent: To: Subject: nikki.detraz@everyactioncustom.com on behalf of Nikki Detraz Friday, October 18, 2019 3:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal   Dear Gabe Roberts,    Hi there. I am writing to oppose the proposal to convert federal funding for TennCare into a “block grant.” This proposal  would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Nikki Detraz  Memphis, TN 38117  nikki.detraz@gmail.com  11 Jonathan Reeve From: Sent: To: Subject: brendajharlan@everyactioncustom.com on behalf of B J Harlan Friday, October 18, 2019 3:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal: Too many people depend on this and need it   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I am acquainted with an individual who has multiple serious health issues, is unable to work and until recently could not  afford healthcare.  She now has Medicaid which is allowing her to get the healthcare she needs so desperately.  This  step for a block grant which cause harm to her and her family.  Please DO NOT pass for the Medicaid Block Grant in  Tennessee.     Sincerely,  B J Harlan  Nashville, TN 37208  brendajharlan@aol.com  12 Jonathan Reeve From: Sent: To: Subject: deanks@everyactioncustom.com on behalf of Sue E.Dean Friday, October 18, 2019 3:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I do not understand why TN lawmakers would want to harm their constituents by reducing the amount of money  available to help the poor and sick of TN to recover. This makes no sense!      I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Sue E. Dean  849 Widgeon Dr  Longmont, CO 80503‐3669  deanks@juno.com  13 Jonathan Reeve From: Sent: To: Subject: pattieanne3@everyactioncustom.com on behalf of Patricia Gilbertson Friday, October 18, 2019 3:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives an already‐ underperforming state  new authority to cut services for these vulnerable populations. The state could eliminate or  restrict services like physical therapy, hospice, and transplant coverage without normal federal oversight – and  arbitrarily limit who gets them. The proposal could also cut back on core health care services like hospital care, without  federal approval or public notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans. It goes against the most basic purpose of the Medicaid program!    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patricia Gilbertson  13221 Stone Heather Dr  Herndon, VA 20171‐4023 pattieanne3@verizon.net  14 Jonathan Reeve From: Sent: To: Subject: l_c_rascal@everyactioncustom.com on behalf of Stephen Verran Friday, October 18, 2019 3:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.   We need to expand Medicaid, not block grants.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Stephen Verran  Oak Ridge, TN 37830  l_c_rascal@yahoo.com  15 Jonathan Reeve From: Sent: To: Subject: lstaylor5880@everyactioncustom.com on behalf of Leianne Taylor Friday, October 18, 2019 3:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     My son, who was born with congenital heart defects, and then at age 8 was diagnosed with brain cancer, has been on  Tenncare his whole life.  Having traditional Medicaid available so that his critical medical needs could be treated  properly has literally meant the difference between life and death for him. He is almost 18 now, and currently is under  the care of seven specialists for his different medical needs, all of which are necessary.   Besides his medical issues, at times the Bureau of Tenncare has not been easy to deal with.  When my son was 7 years  old, Tenncare tried to drop him, just a few months before he was diagnosed with cancer. They accused me of quitting a  part‐time job to avoid paying  for health insurance. I never had credible coverage while working in that position.  If  Tenncare had succeeded, I would have had to choose between caring for my terminally ill son, or working to provide  health insurance for him. Then, three years ago, Tenncare started reviewing my son's coverage again.  They took over  two years, sending additional documentation that needed completion, sometimes 4‐6 months apart, with no final  decision being made until I enlisted the help of the Tennessee Justice Center.  Only then did they finally approve his  coverage to continue. There definitely needs to be more oversight for the Bureau.  Considering everything my son has overcome in his lifetime, he is a walking miracle.  He is about to become an  adult,  one that will be an asset and benefit to our society. His story might be different if his access to complete medical care is  limited.        This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Leianne Taylor  304 Wild Turkey Ln  Soddy Daisy, TN 37379‐3586 lstaylor5880@bellsouth.net  16 Jonathan Reeve From: Sent: To: Subject: wbrodrick@everyactioncustom.com on behalf of Willodene BRODRICK Friday, October 18, 2019 3:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Unfair, Cruel and leaves too many people without health care. Tn. care do better than this. Everyone deserves adequate health care. Please do not pass the block grant.healthOpposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Willodene BRODRICK  3408 Cainbrook Xing  Antioch, TN 37013‐2350 wbrodrick@tds.net  17 Jonathan Reeve From: Sent: To: Subject: jennifersamardak@everyactioncustom.com on behalf of Jennifer Samardak Friday, October 18, 2019 7:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jennifer Samardak  Antioch, TN 37013  jennifersamardak@gmail.com  18 Jonathan Reeve From: Sent: To: Subject: doris.housewright@everyactioncustom.com on behalf of Doris Housewright Friday, October 18, 2019 7:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Doris Housewright  414 Sequoyah Dr  Kingsport, TN 37660‐3744 doris.housewright@yahoo.com  19 Jonathan Reeve From: Sent: To: Subject: amye.warren@everyactioncustom.com on behalf of Amye Warren Friday, October 18, 2019 7:37 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, including my son who is autistic.  We rely on his Medicaid funds for many supports  and services that allow him a measure of independence and healthcare when he cannot work a full time job with a  livable wage.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amye Warren  1313 Windbrook Dr  Hixson, TN 37343‐3099 amye.warren@yahoo.com  20 Jonathan Reeve From: Sent: To: Subject: Linda Bailey Friday, October 18, 2019 7:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Linda Bailey   138 Saligugi Way  Loudon, TN 37774   21 Jonathan Reeve From: Sent: To: Subject: davez385@everyactioncustom.com on behalf of David Zielinski Friday, October 18, 2019 7:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. When do you stop killing poor people? If you  pass this into law you will forever be known as a murderer!!!    Sincerely,  Mr. David Zielinski  385 Mccormick Ln  Crossville, TN 38571‐7117 davez385@frontier.com  22 Jonathan Reeve From: Sent: To: Subject: sls1111@everyactioncustom.com on behalf of Susan Springer Friday, October 18, 2019 7:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a pastor who serves those who depend on Medicaid, I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Susan Springer  Franklin, TN 37064  sls1111@bellsouth.net  23 Jonathan Reeve From: Sent: To: Subject: bethany.waters28@everyactioncustom.com on behalf of Bethany Waters Friday, October 18, 2019 7:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Several friends of mine rely on Medicaid ‐ one of them already struggles with being unable to afford all of her  prescriptions because only a certain number are covered. Her complex medical history and mental health problems  make it difficult to navigate an already complicated system that would only become more murky, less clear, and likely  less helpful for those who really need the help if this proposal is implemented. Making life even more difficult for the  poor and those who often can't fight for themselves is the wrong way to move forward. The US is already at an income  distribution ranking similar to developing countries, per the Gini coefficient ‐ this proposal will serve to hurt the  vulnerable further.    Sincerely,  Bethany Waters  6233 Celtic Dr  Chattanooga, TN 37416‐1446 bethany.waters28@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: dbalderesjr@everyactioncustom.com on behalf of Demetrios Balderes Jr. Friday, October 18, 2019 8:10 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.    Although I do not personally know anyone receiving TennCare, nor do I have work dealings with TennCare, I do know  this is a big mistake for Tennessee.  To expect the State of Tennessee to provide required oversight is beyond reckless.   Please look into how the TN Dept. of Health and TN Atty. General are not adequately overseeing the COPA for Ballad  Health in NE TN, which has already been shown NOT to be to the public's advantage.  I can happily share emails I  received from Mr. Jeff Ockerman and Mr. Larry Fitzgerald that include them contradicting themselves and admitting to  misinforming the public while trying to defend elimination of certain healthcare services our community needs.    And, speaking of the high risks of fraud and abuse re. this proposal, something about this legislation sounds very similar  to another healthcare scheme perpetrated upon our community by one Mr. Alan Levine.  Please look into his work  history (in both the public health and private healthcare spheres) and start to follow the fraud and abuse in other states.  Please do not let Tennessee be further added to that list.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Demetrios Balderes Jr.  Greeneville, TN 37743  dbalderesjr@earthlink.net  25 Jonathan Reeve From: Sent: To: Subject: Eileen Stitzel Friday, October 18, 2019 7:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Eileen Stitzel   116 Bokoshe Cir  Loudon, TN 37774   26 Jonathan Reeve From: Sent: To: Subject: cowanmp@everyactioncustom.com on behalf of Margaret Cowan Friday, October 18, 2019 7:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am writing to oppose changing Tennessee’s Medicaid partnership with the federal government by converting federal  funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Margaret Cowan  1225 Lakeview Dock Rd  Bristol, TN 37620‐0831 cowanmp@me.com  27 Jonathan Reeve From: Sent: To: Subject: starrteem@everyactioncustom.com on behalf of Priscilla Teem Friday, October 18, 2019 8:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I'm not for anything that's gonna hurt people on tn care!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Priscilla Teem  Chattanooga, TN 37407  starrteem@gmail.com  28 Jonathan Reeve From: Sent: To: Subject: deborahbalthrop@everyactioncustom.com on behalf of Deborah Balthrop Friday, October 18, 2019 8:37 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Deborah Balthrop  La Vergne, TN 37086  deborahbalthrop@yahoo.com  29 Jonathan Reeve From: Sent: To: Subject: hannah_lucia13@everyactioncustom.com on behalf of Hannah Lippard Friday, October 18, 2019 8:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Any action that harms the most vulnerable people in the state harms the state as a whole. Any action that does not  protect or care for the most vulnerable Tennesseans cannot be said to protect or care for Tennessee.    Sincerely,  Hannah Lippard  709 Watson Branch Dr  Franklin, TN 37064‐5112 hannah_lucia13@yahoo.com  30 Jonathan Reeve From: Sent: To: Subject: paulsielarkin@everyactioncustom.com on behalf of paul larkin Friday, October 18, 2019 9:04 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  paul larkin  Mosheim, TN 37818  paulsielarkin@gmail.com  31 Jonathan Reeve From: Sent: To: Subject: candacemache@everyactioncustom.com on behalf of Candace Maché Friday, October 18, 2019 8:44 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Candace Maché  Memphis, TN 38107  candacemache@gmail.com  32 Jonathan Reeve From: Sent: To: Subject: carrsonze@everyactioncustom.com on behalf of Carrson Everett Friday, October 18, 2019 9:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Carrson Everett  1402 Fall Creek Rd  Kingsport, TN 37664‐5102 carrsonze@outlook.com  33 Jonathan Reeve From: Sent: To: Subject: ed_brandon_2000@everyactioncustom.com on behalf of Edwin Brandon Friday, October 18, 2019 9:22 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a 36 year survivor of AIDS and 3 time cancer survivor my health care is extremely expensive. Without Medicaid I will  die.I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Edwin Brandon  1655 Carroll Rd  Michie, TN 38357‐4003  ed_brandon_2000@yahoo.com  34 Jonathan Reeve From: Sent: To: Subject: ellearms61@everyactioncustom.com on behalf of Lori Armstrong Friday, October 18, 2019 9:24 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lori Armstrong  Blountville, TN 37617  ellearms61@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: tishedwards95@everyactioncustom.com on behalf of Patricia Edwards Friday, October 18, 2019 9:24 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patricia Edwards  2510 Dickerson Pike  Nashville, TN 37207‐4142 tishedwards95@gmail.com  36 Jonathan Reeve From: Sent: To: Subject: malippard@everyactioncustom.com on behalf of Michael Lippard Friday, October 18, 2019 9:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a pastor, I have contact with numerous people who are hungry, homeless, and/or in need of medical services.  Because there are so many individuals who are vulnerable, I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  Please do not to go forward with this harmful proposal.    Sincerely,  Dr. Michael Lippard  709 Watson Branch Dr  Franklin, TN 37064‐5112 malippard@gmail.com  37 Jonathan Reeve From: Sent: To: Subject: ct220@everyactioncustom.com on behalf of Christy Talley Friday, October 18, 2019 9:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment on Disastrous Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     As a retired Social Worker, I have worked for numerous agencies as well as State government and I've seen how things  go with block grant funding. It inevitably gets cut for a variety of usually not good reasons and these cuts result in people doing without services, treatment, and medications that they need just to survive.  I am also a retired caregiver. My mother lived for 15 years in nursing homes because she was too severely disabled to be  cared for at home. The nursing homes in my area are already horrific due to understaffing and poor care. Any potential  cuts to funding would only make things worse.  Lastly, how dare the State ask Tennesseeans to be the national guinea pigs for this program! They have denied hundreds  of thousands of desperate people ANY health care by refusing to expand Medicaid. People have already been suffering  and dying due to this total lack of concern for them. I have seldom seen such hypocrisy. Our State government has  already proven to us time and time again that they DO NOT care about all of us who depend on or should be receiving  Medicaid. Enough is enough.  This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Christy Talley  Millington, TN 38053  ct220@att.net  38 Jonathan Reeve From: Sent: To: Subject: elizabethabarone@everyactioncustom.com on behalf of Elizabeth Lanphier Friday, October 18, 2019 9:22 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Why I Oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,     Governor Lee has charged that constituents who oppose the Medicaid block grant proposal don’t really “understand it,”  or “have not taken the time” to be informed. It is Governor Lee who is minformed about his constituents, and about the  facts. I have spent the last five years completing a PhD in philosophy, specializing in health care justice. I have spent the  last several years engaged in hospital ethics here in Nashville, where I routinely witness serious yet avoidable health  conditions. These health care tragedies could often be prevented with appropriate access to expanded Medicaid –  access that the state of Tennessee has elected to actively work against, in its unjust policy decisions. We as a state have  the opportunity to work together as health care practitioners, patients, and policy makers to realize the goal that “every  Tennessean should have access to high‐quality health care they can afford.” This is the goal Governor Lee named as one  of his top three priorities in his State of the State Address in January this year. The Medicaid block grant is a step in the  opposite direction of important goal.     Sincerely,  Elizabeth Lanphier  1306 Shelton Ave  Nashville, TN 37216‐3213 elizabethabarone@gmail.com  39 Jonathan Reeve From: Sent: To: Subject: ghharr@everyactioncustom.com on behalf of Gregory Harris Friday, October 18, 2019 9:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose Tennessee's Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Gregory Harris  4912 Kentucky Ave  Nashville, TN 37209‐2212 ghharr@gmail.com  40 Jonathan Reeve From: Sent: To: Subject: carolyngibbons1@everyactioncustom.com on behalf of Carolyn Gibbons Friday, October 18, 2019 9:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] The poor Children and adults will be harmed by Block grants, especially with prescriptions. Doctors will drop the coverage and so will hospitals   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Carolyn Gibbons  1620 Leaside Dr  Kingsport, TN 37664‐2730 carolyngibbons1@gmail.com  41 Jonathan Reeve From: Sent: To: Subject: bradmkaplan@everyactioncustom.com on behalf of BRAD KAPLAN Friday, October 18, 2019 9:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  BRAD KAPLAN  142 Baileyton Rd  Greeneville, TN 37745‐3302 bradmkaplan@gmail.com  42 Jonathan Reeve From: Sent: To: Subject: rogers.leland@everyactioncustom.com on behalf of Leland Rogers Friday, October 18, 2019 9:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans as well as my autistic daughter.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Leland Rogers  7041 Allens Ln  Nashville, TN 37221‐4656 rogers.leland@gmail.com  43 Jonathan Reeve From: Sent: To: Subject: chris45_1977@everyactioncustom.com on behalf of Chris Costner Friday, October 18, 2019 9:29 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.    I am personally affected by this potential block grant, which could affect my coverage on TennCare. I just received a  letter that I could be losing TennCare soon; if that happens I will lose money for medicine and doctor visits, and I can’t  stop my medicine. I am on 14 different medications and have diabetic testing strips which I have documentation for. I  am a recovering opium addict and TennCare has covered for half of my medication, and on anti‐depressants and mood  medications, and would not be able to function properly without these medications.    There's a lot of the damage that’s been done to my body; my body doesn’t produce testosterone and it's made my  depression far worse, because I’ve been on such high doses of painkillers for so many years. I have to rely on the East TN  Human Relations Association to be able to go to the doctors because my wife is at work. I haven’t been able to work  since 2007 because it's been hard to get employed because of my disability. Stopping some of the medications I'm on  can be fatal, and I've doing well physically and I don't want to derail it.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Chris Costner  Newport, TN 37821  chris45_1977@yahoo.com  44 Jonathan Reeve From: Sent: To: Subject: prgordon1@everyactioncustom.com on behalf of Gordon Myers Friday, October 18, 2019 10:04 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    My name is Rev. Gordon Myers and I serve as Pastor of Living Word Lutheran Church, Arlington TN    A. As a called and ordained minister of the Gospel, I attempt to serve the God of all creation revealed to us in both  Scripture and in the person of Jesus the Christ.    •  Again and again in the pages of Scripture, both Old and New Testaments we learn of a God of compassion,  mercy and love that invites us into the living practice and emulation of those same qualities, values and priorities.  Love  of God is expressed in love of neighbor.    •  In Mathew’s Gospel, the 25th chapter Jesus himself teaches that Governments, not just individuals, will be  judged on how well they respond with compassion to the needs of the “Least of these” among us and lifts up the  principle that we are to treat those in need as if they were Our Lord and Savior himself, standing before us.    •  These values and principles are by no means unique to Christian Tradition but are reflected in sacred teachings  of Islam, Judaism, Buddhism, Native Americans, and others around the world.        B.  As a Citizen, I hear those same principles and standards echoed in the TN CONSTITUTION which declares:   Article 1. Declaration of Rights   •  Section 1. That all power is inherent in the people, and all free governments arefounded on their authority, and  instituted for their peace, safety, and happiness;     C. Few things in life are more critical to “peace, safety, and happiness” of all people than access to health care, medical  attention and treatments and interventions which promote healing and wholeness.    D. With those principles as guidance, I am concerned about the Block Grant Proposal.    As I read the proposal, its primary objective appears to be to reduce the budgetary effects of caring for the “least of  these among us” by:  •  Reducing oversight and compliance with federal guidelines for both standards and quality of care and   •  having more independent latitude in determining who qualifies for care.  •  While Incentivizing cuts and resulting “cost‐savings” to accrue to the State’s budget’s benefit.      E.  In a health care system and model whose economics are dominated by Health Insurance Companies already  incentivized by the profits to deny treatment, and health providers who are incentivized to maximize profits by focusing  on providing care and competing for those patients with the ability to pay… This seems to be a plan uniquely unlikely to  promote the peace, safety, and happiness of the people of Tennessee, especially for the “least of these among us”    F.  And this proposal comes at a time and context in which,   •  in the past two years TennCare has cut off 200,000 children, many of the them whom qualified for eligibility  •  The rate of insurance coverage among children is declining  45 •  Medical debt is climbing  •  And those with pre‐existing conditions are finding it difficult to get coverage   •  Many of our communities both urban and rural are decimated by drug usage, mental health and violence issues. •  10.4 % of Tennessee’s older adults are food insecure… and thus more likely to have to choose between health  care and basic nutrition.  •  295,600 Children face hunger in our state.  •  SNAP is facing new reductions…Used by 543,000 households in Tennessee,  even though the program is related  to a 53% in reduction of childhood obesity rates among participants. A major contribution to health of our children.     G My ministry brings me into contact with people in poverty and at the margins of our society.  My experience in  Tennessee as I assist people attempting to access care has been very frustrating.  •  I have spent hours on the phone trying to get through to TENNCARE customer service on behalf of  others, with  calls that never get answered, and websites that offer no alternative form of contact to resolve issues.  •  It can take more than a year to qualify someone with disabilities for a program like Community First Choices, but  then actually accessing the care is difficult, especially for    Sincerely,  Rev Gordon Myers  11167 Orville Cv  Arlington, TN 38002‐4369 prgordon1@att.net  46 Jonathan Reeve From: Sent: To: Subject: dragonkatet2000@everyactioncustom.com on behalf of Corina Ravenscraft Friday, October 18, 2019 9:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Corina Ravenscraft  1807 Warren Dr  Clarksville, TN 37040‐6738 dragonkatet2000@yahoo.com  47 Jonathan Reeve From: Sent: To: Subject: mooremedia@everyactioncustom.com on behalf of Gary Moore Friday, October 18, 2019 9:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Gary Moore  Cordova, TN 38016  mooremedia@att.net  48 Jonathan Reeve From: Sent: To: Subject: theatracal@everyactioncustom.com on behalf of Carole Caprio Friday, October 18, 2019 9:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Just to be brief, this proposal is SHAMEFUL and INHUMANE!!!  Many Tennesseans will be harmed by this outrageous  plan.       I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.       Sincerely,  Ms. Carole Caprio  97 Mcclures Bend Ln  Carthage, TN 37030‐2309 theatracal@aol.com  49 Jonathan Reeve From: Sent: To: Subject: shwabie@everyactioncustom.com on behalf of Lynda Thompson Friday, October 18, 2019 10:05 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lynda Thompson  1709 Russell St  Nashville, TN 37206‐2047 shwabie@bellsouth.net  50 Jonathan Reeve From: Sent: To: Subject: jim48103@everyactioncustom.com on behalf of James Gurney Friday, October 18, 2019 9:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Strongly Opposed to Medicaid Block Grant Proposal   Dear Gabe Roberts,    Dear Mr. Roberts,    I am a public health professional. With all respect, I am strongly opposed to the block grant proposal. I believe the block  grant proposal provides far too much flexibility for the funds to be used for purposes other than direct health care for  vulnerable persons in Tennessee, and it allows for far too little oversight by the federal government. The working poor  have greatly benefited from Medicaid expansion in 37 other states in the US. Tennessee citizens are helping to pay for  those services in the other states. All our citizens in TN deserve to have access to affordable health care ‐ that will not be  the case with the block grant experiment. Please reconsider this flawed proposal and instead adopt Medicaid expansion. Thank you for the opportunity to express my view.    Sincerely,    James Gurney  Germantown, TN    Sincerely,  James Gurney  2104 Duntreath Mdws  Germantown, TN 38139‐3524 jim48103@gmail.com  51 Jonathan Reeve From: Sent: To: Subject: tperry1131@everyactioncustom.com on behalf of Teresa Perry Friday, October 18, 2019 9:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Teresa Perry  1600 John Lee Ln  Murfreesboro, TN 37129‐3707 tperry1131@gmail.com  52 Jonathan Reeve From: Sent: To: Subject: seeworthy@everyactioncustom.com on behalf of Judith Hoskins Friday, October 18, 2019 9:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Please do not change Tennessee’s Medicaid partnership with the federal government by converting federal funding for  TennCare into a “block grant.” This proposal could cause immense harm and jeopardize coverage for vulnerable  Tennesseans like my son.     Medicaid was created to help the most vulnerable Americans get vital health coverage they need. This proposal goes  against the objectives of Medicaid because it gives Tennessee new authority to cut these services, to eliminate or  restrict services like physical therapy, hospice, and transplant coverage without normal federal oversight – and  arbitrarily limit who gets them. The proposal could also cut back on core health care services like hospital care, without  federal approval or public notice, and exclude coverage of the most effective prescription drugs.     TennCare needs federal oversight and federal standards, in place for the protection of patients.  Without such  guardrails, I'm afraid the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver goes against the purpose of the Medicaid program. I respectfully urge you not to go forward with this  harmful proposal.    Thanks for your consideration of vulnerable young people with developmental disabilities like my son, who depend on  this coverage to help them live as independently as possible.    Sincerely,  Judith Hoskins  Nashville, TN 37209  seeworthy@juno.com  53 Jonathan Reeve From: Sent: To: Subject: Sailormoon898@everyactioncustom.com on behalf of Selina Cloninger Friday, October 18, 2019 9:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Selina Cloninger  1213 Amersham Cir  Kingsport, TN 37660‐5708 Sailormoon898@yahoo.com  54 Jonathan Reeve From: Sent: To: Subject: amyjacksoncc@everyactioncustom.com on behalf of Amy Jackson Friday, October 18, 2019 10:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Access to health care saves lives and money for disadvantaged  and all Americans. Why consider a block grant that can  go awry in terms of caring for people appropriately. This is unjust, in humane, illogical and not smart.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amy Jackson  Nashville, TN 37210  amyjacksoncc@aol.com  55 Jonathan Reeve From: Sent: To: Subject: rusty.hands.brown@everyactioncustom.com on behalf of Rusty Brown Friday, October 18, 2019 10:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rusty Brown  1207 Lumsley Dr  Lebanon, TN 37087‐1587  rusty.hands.brown@gmail.com  56 Jonathan Reeve From: Sent: To: Subject: wbloc@everyactioncustom.com on behalf of Wilson Horick Friday, October 18, 2019 10:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    If this proposal saves money for the state, it will be on the backs of the most vulnerable among our neighbors ‐‐ one of  my own neighbors among them ‐‐ and the cost will be paid in human lives and suffering.     Sincerely,  Mr. Wilson Horick  220 Mockingbird Rd  Nashville, TN 37205‐1832 wbloc@bellsouth.net  57 Jonathan Reeve From: Sent: To: Subject: Allison@everyactioncustom.com on behalf of Allison Donald Friday, October 18, 2019 10:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I am oppsed to the [proposed block grant. As a person living with a disability I belive that this prosed block grant will cut services and supports for many in my community.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Allison Donald  5100 Poplar Ave Ste 810 Memphis, TN 38137‐3104 Allison@mcil.org  58 Jonathan Reeve From: Sent: To: Subject: whittlz@everyactioncustom.com on behalf of Whitney Pastorek Friday, October 18, 2019 10:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    The below is a form letter. It doesn’t matter ‐ you’re not gonna read this anyway, because our governor and his  administration don’t care about the lives of ordinary Tennesseans. But I couldn’t let this public comment period go by  without registering my disgust about it. Just expand Medicaid like you should have done years ago. Put people over  politics. Do your job. Ok. On with the form letter:    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Whitney Pastorek  Nashville, TN 37216  whittlz@whittlz.com  59 Jonathan Reeve From: Sent: To: Subject: etchitty@everyactioncustom.com on behalf of Em Chitty Friday, October 18, 2019 10:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I have dear friends who have relied on TennCare for their health care. They are working artists and have had multiple  heaIth problems, but TennCare has helped them continue in their important work with war‐damaged veterans.      am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal gives Tennessee new authority to cut services for these vulnerable  populations. The state could eliminate or restrict services like physical therapy, hospice, and transplant coverage  without normal federal oversight – and arbitrarily limit who gets them. The proposal could also cut back on core health  care services like hospital care, without federal approval or public notice, and exclude coverage of the most effective  prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Em Chitty  7021 Nubbin Ridge Dr  Knoxville, TN 37919‐8123 etchitty@gmail.com  60 Jonathan Reeve From: Sent: To: Subject: zjsmith525@everyactioncustom.com on behalf of Jerry Smith Friday, October 18, 2019 10:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Jerry Smith  525 Anderson Ln  Madison, TN 37115‐2913  zjsmith525@gmail.com  61 Jonathan Reeve From: Sent: To: Subject: pressoncpa@everyactioncustom.com on behalf of Blair Presson Friday, October 18, 2019 10:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment SUPPORTING Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am supporting the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would give the state of Tennessee the  opportunity to adapt and fine tune it's medicaid related services to become more efficient and cost effective, and  thereby help guarantee the viability of the system for Tennessee's most needy.    Keeping and even expanding the system in it's current form would create a huge potential economic liability for the  state in future years and costs of the current system continue to rise exponentially.   If  Tennessee had to them curtail  services at that point that would put an even greater burden on Tennessee's poor families to adjust or create a  potentially unsustainable burden on our state's citizens when tax rates had to be increased to pay for increased future  costs, or other areas of state government would have to be curtailed to make up the deficit.    The black grant gives Tennessee's lawmakers the best opportunity to position our state to meet the medical needs of  the poor in the most effective way possible and to adjust more quickly to changes than what the current system offers.    Sincerely,  Mr. Blair Presson  78 Jacob St  Jackson, TN 38305‐7379  pressoncpa@bellsouth.net  62 Jonathan Reeve From: Sent: To: Subject: karenwtj@everyactioncustom.com on behalf of Karen W Friday, October 18, 2019 10:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Karen W  Hixson, TN 37343  karenwtj@bellsouth.net  63 Jonathan Reeve From: Sent: To: Subject: amos.powers@everyactioncustom.com on behalf of Amos Powers Friday, October 18, 2019 9:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Amos Powers  164 W Wall St # A‐2 Cookeville, TN 38506‐2303 amos.powers@live.com  64 Jonathan Reeve From: Sent: To: Subject: jessegore@everyactioncustom.com on behalf of Jesse Gore Friday, October 18, 2019 10:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Jesse Gore  2411 Chapel Ave  Nashville, TN 37206‐2229 jessegore@yahoo.com  65 Jonathan Reeve From: Sent: To: Subject: mparkerlaw@everyactioncustom.com on behalf of Mary Parker Friday, October 18, 2019 9:52 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I absolutely oppose the block grant proposal for TennCare   Dear Gabe Roberts,    My clients who desperately need Medicaid have a difficult enough time, but, by converting federal funding for TennCare  into a “block grant" will be extremely harmful to many needy people. This proposal would cause immense harm and  jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mary Parker  5113 Fountainhead Dr  Brentwood, TN 37027‐5809 mparkerlaw@aol.com  66 Jonathan Reeve From: Sent: To: Subject: karl@everyactioncustom.com on behalf of Karl Warden Friday, October 18, 2019 10:08 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Karl Warden  1504 17th Ave S  Nashville, TN 37212‐2806 karl@karlwarden.net  67 Jonathan Reeve From: Sent: To: Subject: fatmama52@everyactioncustom.com on behalf of Geraldine Downey Friday, October 18, 2019 10:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose Medicaid Block Grants   Dear Gabe Roberts,    Matthew 25th Chapter (31st‐46th Verse) Reads:    “When the Son of Man comes in His glory, and all the [a]holy angels with Him, then He will sit on the throne of His glory.  32 All the nations will be gathered before Him, and He will separate them one from another, as a shepherd divides his  sheep from the goats. 33 And He will set the sheep on His right hand, but the goats on the left. 34 Then the King will say  to those on His right hand, ‘Come, you blessed of My Father, inherit the kingdom prepared for you from the foundation  of the world: 35 for I was hungry and you gave Me food; I was thirsty and you gave Me drink; I was a stranger and you  took Me in; 36 I was naked and you clothed Me; I was sick and you visited Me; I was in prison and you came to Me.’    37 “Then the righteous will answer Him, saying, ‘Lord, when did we see You hungry and feed You, or thirsty and give You  drink? 38 When did we see You a stranger and take You in, or naked and clothe You? 39 Or when did we see You sick, or  in prison, and come to You?’ 40 And the King will answer and say to them, ‘Assuredly, I say to you, inasmuch as you did it  to one of the least of these My brethren, you did it to Me.’    41 “Then He will also say to those on the left hand, ‘Depart from Me, you cursed, into the everlasting fire prepared for  the devil and his angels: 42 for I was hungry and you gave Me no food; I was thirsty and you gave Me no drink; 43 I was a  stranger and you did not take Me in, naked and you did not clothe Me, sick and in prison and you did not visit Me.’    44 “Then they also will answer [b]Him, saying, ‘Lord, when did we see You hungry or thirsty or a stranger or naked or  sick or in prison, and did not minister to You?’ 45 Then He will answer them, saying, ‘Assuredly, I say to you, inasmuch as  you did not do it to one of the least of these, you did not do it to Me.’ 46 And these will go away into everlasting  punishment, but the righteous into eternal life.”    The sickest, the poorest, and the neediest are covered by TNCare. My husband and I are among the sickest, poorest, and  neediest. We are both retired (disabled), and live on social security, and are deeply dependent on TN CARE/Medicaid for  our medical services and supports. Until 5 months ago, my husband was a pillar in the community. He's served his  country in the US Navy. He's spent the last 53 years of his life in partnership with me as we've raised one daughter. He is  a deacon, little league coach, and "granddad" to hundreds of children in the church programs run by out of our church,  Christ Quest Community Church. After a fall on June 11th, he went into cardiac arrest, and suffered a permanent brain  injury. He now requires 24 hour care. He's been in 3 hospitals and 2 nursing homes since June. Getting the necessary  help for him would ONLY have been possible by TN CARE as a supplement to his Medicare plan.    We had a meeting recently with his skilled nursing facility. He's being discharged this week, and my daughter and I were  preparing for the discharge and figuring out how the two of us would provide the same 24 hour care that he's received  for the last five months.  Reduced service and reduced availability of providers has been my life story in a way I could not  have imagined, and block grants would encourage more "cost savings" and fewer services for families like ours.     Mr. Roberts, we need expanded Medicaid, not block grants and limited federal oversight. Please consider the people of  TN, not big business, shareholders or profits.     68   Sincerely,  Geraldine Downey  615 Wicks Ave  Memphis, TN 38126‐5720  fatmama52@gmail.com  69 Jonathan Reeve From: Sent: To: Subject: pastorschalk@everyactioncustom.com on behalf of Ingrid Schalk Friday, October 18, 2019 10:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a Lutheran paster serving serving in Tellico Village in Loudon. We are activity engaged with agencies in Loudon and  Monroe counties who assist the homeless and impoverished in these communities. We see them each week. We hear  their stories. Often, we feel helpless in providing for their many needs. One is very obvious ‐ these vulnerable ones are in  dire need of healthcare.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Pastor Ingrid Schalk  143 Chota Ctr  Loudon, TN 37774‐2886  pastorschalk@yahoo.com  70 Jonathan Reeve From: Sent: To: Subject: dishmanx2@everyactioncustom.com on behalf of Patricia Dishman Friday, October 18, 2019 10:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment OPPOSING Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am very much opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government.   This proposal which would  convert federal funding for TennCare into a “block grant" would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal violates the objectives of Medicaid by giving Tennessee new authority to  cut services for these vulnerable populations. The state could eliminate or restrict services like physical therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The proposal could also  cut back on core health care services like hospital care, without federal approval or public notice, and exclude coverage  of the most effective prescription drugs.     TennCare needs MORE accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or by eliminating federal standards which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed. It goes against the goals and purpose of the Medicaid program. We respectfully  urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Patricia Dishman  914 Briarwood Crst  Nashville, TN 37221‐4351 dishmanx2@aol.com  71 Jonathan Reeve From: Sent: To: Subject: mattduning@everyactioncustom.com on behalf of Matt Duning Friday, October 18, 2019 10:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Matt Duning  Madisonville, TN 37354  mattduning@yahoo.com  72 Jonathan Reeve From: Sent: To: Subject: tdsstrange@everyactioncustom.com on behalf of Tracy Strange Friday, October 18, 2019 10:29 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Tracy Strange  Church Hill, TN 37642  tdsstrange@gmail.com  73 Jonathan Reeve From: Sent: To: Subject: brendelvc@everyactioncustom.com on behalf of Barbara Van Camp Friday, October 18, 2019 10:23 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Barbara Van Camp  2198 Courtland Pl  Memphis, TN 38104‐4215 brendelvc@yahoo.com  74 Jonathan Reeve From: Sent: To: Subject: shanaminkin@everyactioncustom.com on behalf of Shana Minkin Friday, October 18, 2019 10:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Shana Minkin  109 Wiggins Creek Dr  Sewanee, TN 37375‐3032 shanaminkin@gmail.com  75 Jonathan Reeve From: Sent: To: Subject: kevingreer@everyactioncustom.com on behalf of Robert Greer Friday, October 18, 2019 10:29 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Bill Lee + Alan Levine + Block Grants = NO!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Robert Greer  329 Norma Dr  Kingsport, TN 37660‐6770  kevingreer@aol.com  76 Jonathan Reeve From: Sent: To: Subject: milliken@everyactioncustom.com on behalf of Judy Milliken Friday, October 18, 2019 10:04 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I am opposed to the proposed block grant proposal. Please listen to all the individuals directly affected by these unknown changes to the medicaid program in Tennessee. Many individuals lives that can't help themselves are depending on this ...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Judy Milliken  916 N Graycroft Ave  Madison, TN 37115‐2517 milliken@memfoundation.org  77 Jonathan Reeve From: Sent: To: Subject: gerald@everyactioncustom.com on behalf of GERALD LOVEL Friday, October 18, 2019 10:22 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I strongly oppose the idea of the state of Tennessee taking over Medicaid and converting it to a block grant. Right now,  Medicaid requires TN to provide services to enrollees based federal guidelines. Right now, the US government offers TN  the opportunity to expand Medicare in the state with federal dollars, and Tennessee has refused to do so.     I have a fully disabled adult daughter on TennCare/Medicaid. The state of Tennessee is required to provide 40 hours of  nursing care per week so I can work. This week, you provided 8 of the 40 hours. I am at home, caring for my daughter,  right now because of this service failure. We are supposed to receive ongoing PT, OT, and ST services. We are not  receiving these services today because your managed care contractor, UHC, requires a pre‐approval for services which  they will not issue because they do not know how to. This is totally ridiculous.    Nothing in your block grant proposal states that you will continue to provide mandated care, or care of any sort, to  patients and caregivers like me who depend on it today. If TN already cannot do this job, as I have mentioned, why  should I trust TN to do more with a block grant?     No, I understand that the block grant will be diverted to hire more third‐party administration groups such as UHC, while  reducing actual services to clients. With the record Tennessee has today, it is hard to come to any other conclusion.    I strongly object to Tennessee's refusal to expand Medicaid, while saying you will do better with a block grant. PROVE IT  before adopting this change ... I'm waiting ...    Sincerely,  GERALD LOVEL  1817 N Parkway  Memphis, TN 38112‐5021  gerald@lovels.us  78 Jonathan Reeve From: Sent: To: Subject: rogerwjohnson9@everyactioncustom.com on behalf of Roger Johnson Friday, October 18, 2019 10:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Roger Johnson  111 Pickwick Ln  Oak Ridge, TN 37830‐5207 rogerwjohnson9@gmail.com  79 Jonathan Reeve From: Sent: To: Subject: WarEagleBebbie@everyactioncustom.com on behalf of Elizabeth Wright Minter Friday, October 18, 2019 10:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Do the Next Right Thing!   Dear Gabe Roberts,    My unequivocal opposition  to changing Tennessee’s Medicaid partnership with the U. S. Government is because, in  spite of my having been fortunate enough to  have had private coverage through my teaching/school counseling, as well  as through my husband’s forty years as a public school teacher, counselor, and administrator. This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans. I, personally, am terrified.     When I was seventeen, my forty‐three‐year‐old mother lost her heroic fight against melanoma, leaving my seven, ten,  and fifteen‐year‐old siblings with Daddy, a man who had children ONLY because mother knew all her life that she  wanted four children, and was clear about that with anyone she considered becoming serious with, and she “stuck to  her guns”!    Before she died, in 1965, she said to me, “Bebbie dear, ours is becoming a Nation in which ONLY the very poor and the  very wealthy can AFFORD TO BECOME ILL AND DIE!” Her words resound in my mind and my heart each and every time I  go to a doctor.     Medicaid was created to help vulnerable Americans, those to whom the Bible refers as “the least of these,” get vital  health coverage MANY need. This proposal goes against the objectives of Medicaid, as it gives Tennessee new authority  to cut services for our most  vulnerable, yet valuable,  populations. The state could eliminate or restrict vital services like  physical therapy, hospice, transplant coverage without crucial oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs MORE accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for OUR protection! Without such  guardrails, the state could return to the days when managed care contractors failed to provide care to patients and  providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital health coverage  for Tennesseans.     This “waiver” is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid  program, and against the teachings of all major faiths. It is in opposition to basic human rights! I respectfully urge you  NOT to go forward with this potentially deadly  proposal.    In hope, tinged with fear of a “No” vote,    Elizabeth Wright Minter  (615)969‐3750    Sincerely,  Elizabeth Wright Minter  2707 Dorian Blvd  Murfreesboro, TN 37130‐3204 WarEagleBebbie@gmail.com  80 Jonathan Reeve From: Sent: To: Subject: joshuagrossss@everyactioncustom.com on behalf of Joshua Gross Friday, October 18, 2019 10:44 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joshua Gross  2120 B Lebanon Pike # 113 Nashville, TN 37210‐2404 joshuagrossss@gmail.com  81 Jonathan Reeve From: Sent: To: Subject: emilykatefulmer@everyactioncustom.com on behalf of Emily Fulmer Friday, October 18, 2019 9:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I understand that because the state legislature passed HB1280 that TennCare is required to submit a proposal to the  Federal Government on this.  But, doing so will harm us. It makes the most vulnerable Tennesseans the guinea pigs in a  harmful national experiment and it is morally wrong.    Every comment at every public hearing across the state was AGAINST this proposal. Please listen to the people of this  state who will be affected and stop this block grant proposal by any means necessary.    Sincerely,  Mrs. Emily Fulmer  4515 Planters Trace Ln  Collierville, TN 38017‐9351 emilykatefulmer@gmail.com  82 Jonathan Reeve From: Sent: To: Subject: srasmuss@everyactioncustom.com on behalf of Susan Rasmussen Friday, October 18, 2019 10:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Susan Rasmussen  926 Watauga St  Kingsport, TN 37660‐4457 srasmuss@charter.net  83 Jonathan Reeve From: Sent: To: Subject: dkgallaher@everyactioncustom.com on behalf of Diana Gallaher Friday, October 18, 2019 10:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the block grant as a funding mechanism for Tennessee's Medicaid program, TennCare. I work with  people who are disabled. The large majority of the people I assist are under 135% of the federal poverty level. They are  challenged every single month just to make ends meet. Changing TennCare to a fixed amount of money and saying it will  allow for the same level or more services is not logical. Why is the state of Tennessee borrowing trouble? Why are  Tennesseans paying for other states to expand their Medicaid programs and refusing to take the billions offered by the  federal government to expand TennCare?    Sincerely,  Diana Gallaher  916 Phelan Dr  Lebanon, TN 37090‐5025  dkgallaher@yahoo.com  84 Jonathan Reeve From: Sent: To: Subject: rbigelow@everyactioncustom.com on behalf of Robert Bigelow Friday, October 18, 2019 10:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Strenuously Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Robert Bigelow  203 Copley Ln  Nashville, TN 37204‐3245  rbigelow@bigelowlegal.com  85 Jonathan Reeve From: Sent: To: Subject: annngeoffshaw@everyactioncustom.com on behalf of Ann Shaw Friday, October 18, 2019 10:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.  These people are the most at risk and shouldn’t have to die early for the state to  save a few dollars. Do what’s right!!!!    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ann Shaw  Whites Creek, TN 37189  annngeoffshaw@yahoo.com  86 Jonathan Reeve From: Sent: To: Subject: beverly38058@everyactioncustom.com on behalf of Beverly Sneed Friday, October 18, 2019 10:42 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Beverly Sneed  1201 Tabernacle Rd  Covington, TN 38019‐7823 beverly38058@yahoo.com  87 Jonathan Reeve From: Sent: To: Subject: emilymabry@everyactioncustom.com on behalf of Emily Mabry Friday, October 18, 2019 10:52 AM PUBLICE NOTICE TENNCARE [EXTERNAL] AIM Center Disability Advocate   Dear Gabe Roberts,    I am an employment specialist working for AIM under a state grant providing support to members who are disabled and  receiving TennCare. I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans, many of which I work with every day.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Emily Mabry  472 W Martin Luther King Blvd  Chattanooga, TN 37402‐1631 emilymabry@aimcenterinc.com  88 Jonathan Reeve From: Sent: To: Subject: nancytennent@everyactioncustom.com on behalf of Nancy Tennent Friday, October 18, 2019 9:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Nancy Tennent  312 Starling Ln  Franklin, TN 37064‐8639 nancytennent@me.com  89 Jonathan Reeve From: Sent: To: Subject: cathryn@everyactioncustom.com on behalf of cathryn armistead Friday, October 18, 2019 10:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  mrs cathryn armistead  1050 Hamilton Station Blvd Ste 200 Lebanon, TN 37087‐1628 cathryn@mcbrienlawgroup.com  90 Jonathan Reeve From: Sent: To: Subject: rashmi.r.bharadwaj@everyactioncustom.com on behalf of Rashmi Bharadwaj Friday, October 18, 2019 10:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Proposals = Neglecting America's Most Vulnerable Individuals   Dear Gabe Roberts,    As a student interested in health policy and who has worked with at‐risk populations, healthcare is critical for the  betterment of our poorest and most vulnerable population. Specifically, Medicaid is designed to provide assistance for  individuals who would otherwise not be able to afford and receive access to preventative and generalized care. With a  block‐grant, Tennessee is debilitating its ability to care for these individuals while increasing the state's economic burden  in three main ways.    1. A block grant is essentially a one‐time lump‐sum of money that the state receives to fund Medicaid. If Medicaid ends  up being more expensive, the state would either bare the costs or people would loose coverage. Without a block grant,  the neediest could have healthcare coverage at the federal government's expense, reducing the amount of money the  state would have to put towards the program.    2. If more individuals are kicked off of Medicaid because Tennessee accepts a block‐grant, then these individuals would  be subject to increased health risks. Since the individuals would find it difficult to afford healthcare, they would wait  until the last possible moment to seek care, which is often harmful to the patient and expensive for health care facilities.  Medicaid is designed to help people have access to forms of preventative care that can help reduce complicated and  costly health issues.    3. Along the same lines of the second point, the individuals without Medicaid could end up becoming too sick and  unable to contribute to society. This would be considered a loss of productivity in Tennessee's economy.    Accepting a block‐grant is a lose‐lose situation that will end up costing Tennessee much more than it thinks it would  save. The above risks are highly likely and need to be kept in mind when considering to implement block‐grants. There is  a reason why other states have not jumped to ask for block‐grants for funding their Medicaid programs.     Sincerely,  Rashmi Bharadwaj  Nashville, TN 37235  rashmi.r.bharadwaj@vanderbilt.edu  91 Jonathan Reeve From: Sent: To: Subject: Blake Leyers Friday, October 18, 2019 11:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Blake Leyers   5969 Hitching Post Lane  Nashville, TN 37211   92 Jonathan Reeve From: Sent: To: Subject: fabiola.carrion@everyactioncustom.com on behalf of Fabiola Carrion Friday, October 18, 2019 10:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am completely opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans. It is also legally suspect.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  Instead, you should expand Medicaid to make sure that more Tennesseans have access to health care.     Proposing a Medicaid block grant does not give us any flexibility. How does capping fund give us more freedom? What  you are doing with this proposal is saying to the people of Tennessee, you are only allowed to have limited access to  health care. Everyone else in the country has as much as they need, but not if you are in Tennessee. This proposal is  cruel and senseless.     Sincerely,  Fabiola Carrion  Memphis, TN 38107  fabiola.carrion@gmail.com  93 Jonathan Reeve From: Sent: To: Subject: arnoldd423@everyactioncustom.com on behalf of Donna Srnold Friday, October 18, 2019 11:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Donna Srnold  Kingsport, TN 37660  arnoldd423@yhoo.com  94 Jonathan Reeve From: Sent: To: Subject: kglowery@everyactioncustom.com on behalf of Kathy Lowery Friday, October 18, 2019 11:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Please do not put vulnerable people at risk of losing health care.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Kathy Lowery  300 Wheatfield Cir Apt B228 Brentwood, TN 37027‐4497 kglowery@gmail.com  95 Jonathan Reeve From: Sent: To: Subject: Deana_Claiborne@everyactioncustom.com on behalf of Deana Claiborne Friday, October 18, 2019 11:13 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Any Tennessee Medicaid program must be designed to include all federally eligible applicants, without waiting lists. The  program also must be designed to ensure that federal funding is flexible to meet increased cost‐of‐care needs  (comparable to that of other states), and available to address the substantially increased Medicaid population that will  need services when the "baby boomer" population reaches an age where significant Medicaid supports are needed.  Moreover, the program also must address substantial long‐term needs of children with developmental disabilities and  others who require essential long‐term supports. The plan as presented is dangerous to all of these critical needs  populations, and it will either result in unnecessary deaths or an unreasonable burden on Tennessee taxpayers.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.       Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Deana Claiborne  524 Plantation Ct  Nashville, TN 37221‐2501 Deana_Claiborne@ucpnashville.org  96 Jonathan Reeve From: Sent: To: Subject: kathylcarter@everyactioncustom.com on behalf of Kathy Carter Friday, October 18, 2019 10:49 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathy Carter  2055 Wilson Ln  Goodlettsville, TN 37072‐9321 kathylcarter@gmail.com  97 Jonathan Reeve From: Sent: To: Subject: tlsmallwood52@everyactioncustom.com on behalf of Teresa Smallwood Friday, October 18, 2019 11:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Teresa Smallwood  Nashville, TN 37221  tlsmallwood52@hotmail.com  98 Jonathan Reeve From: Sent: To: Subject: faydelk@everyactioncustom.com on behalf of Fay L Delk Friday, October 18, 2019 10:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Block grants have a history of being used to cut funding for government services. Tennessee could serve its citizens  much better by expanding Medicaid. It is indeed difficult to trust the choices to be made by people who limit   community support for citizens' access to health care coverage because they are too low income, despite working.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Fay L Delk  6680 Charlotte Pike Apt K10 Nashville, TN 37209‐4230 faydelk@gmail.com  99 Jonathan Reeve From: Sent: To: Subject: Theresa Marchese Friday, October 18, 2019 11:18 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant proposal   Just vote no.  Be a hero and not a zero.  This will threaten healthcare for many Tennesseans.  It has been proven that it  will not only be ineffective but cause many to lose healthcare.  Value the opinions of the citizenry and the experts'  opinions.  This should NOT be allowed to be the law of the land.  Thanks.    Theresa Marchese, 37221  100 Jonathan Reeve From: Sent: To: Subject: steve.825@everyactioncustom.com on behalf of steve powell Friday, October 18, 2019 11:09 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  steve powell  Lawrenceburg, TN 38464  steve.825@hotmail.com  101 Jonathan Reeve From: Sent: To: Subject: margcas@everyactioncustom.com on behalf of Marga Caste Friday, October 18, 2019 11:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I want to see Tennessee be a leader in humane and honorable treatment of all its citizens, not one that goes through the back door to punish those least able to protect themselves.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marga Caste  208 E Church St  Greeneville, TN 37745‐5076 margcas@yahoo.com  102 Jonathan Reeve From: Sent: To: Subject: tracy.oconnor@everyactioncustom.com on behalf of Tracy O'Connor Friday, October 18, 2019 11:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I was on TennCare when my oldest son was born and it allowed both of us to experience a safe delivery. He was born  prematurely but as I had no choice but to go back to work to support us, he had to go to daycare at just 2 months  old.  TennCare covered vaccinations that helped him to avoid RSV, which he was particularly vulnerable to because of his  prematurity and being in a day care environment.  Being able to work that year allowed me to become fully self  sufficient and now my son is 17 and an honors student on his way to the University of Tennessee. I am grateful that  thanks to TennCare we are a success story.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Tracy O'Connor  160 N Evergreen St  Memphis, TN 38104‐6421 tracy.oconnor@gmail.com  1 Jonathan Reeve From: Sent: To: Subject: jonmwilliamson@everyactioncustom.com on behalf of Jon Williamson Friday, October 18, 2019 11:28 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jon Williamson  3217 Blue Sky Dr  Murfreesboro, TN 37130‐1530 jonmwilliamson@gmx.com  2 Jonathan Reeve From: Sent: To: Subject: mountvu@everyactioncustom.com on behalf of Judith Saks Friday, October 18, 2019 11:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    With 200,000 children wiped off the TennCare rolls and rural hospitals closing at an unprecedented rate, our state  stands out among all states as ignoring the healthcare needs of the most vulnerable. By not expanding Medicaid, which  would bring our tax dollars back to Tennessee, we are perpetuating our standing at the bottom of the list of states  denying healthy lives to those who can’t afford afford to pay.   This block grant proposal will be a great detriment to our state’s subpar healthcare services to the poor.   I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Judith Saks  742 Harpeth Trace Dr  Nashville, TN 37221‐3140 mountvu@att.net  3 Jonathan Reeve From: Sent: To: Subject: phyllis@everyactioncustom.com on behalf of Phyllis Rose Friday, October 18, 2019 11:23 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     TennCare needs more accountability, not less.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal. Stop harming poor people.    Sincerely,  Phyllis Rose  629 Harpeth Trace Dr  Nashville, TN 37221‐3147 phyllis@828marketing.com  4 Jonathan Reeve From: Sent: To: Subject: reuledeb@everyactioncustom.com on behalf of Deborah Farringer Friday, October 18, 2019 11:26 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    In addition to all of the above, this action seems to be on rocky footing from a funding perspective and could end up  costing Tennessean tax payouts money to defend. Under federal law, CMS only has authority to appropriate funds in  accordance with the process set forth under the Medicaid Act. The agency does not have authority to appropriate funds  in a manner other than as set forth under the enacting statute. Instead of undertaking a block grant program prior to a  federal statute that properly allocates those funds, TennCare should spend time and money and resources ensuring  coverage of needy children and vulnerable populations.     Sincerely,  Deborah Farringer  3618 Richland Ave  Nashville, TN 37205‐2356 reuledeb@yahoo.com  5 Jonathan Reeve From: Sent: To: Subject: Debra.Transue@everyactioncustom.com on behalf of Debra Transue Friday, October 18, 2019 11:38 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Debra Transue  140 E Swan St  Centerville, TN 37033‐1445 Debra.Transue@ascension.org  6 Jonathan Reeve From: Sent: To: Subject: merrilee.wineinger@everyactioncustom.com on behalf of Merrilee Wineinger Friday, October 18, 2019 11:29 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a Tennessean and clergy member in the United Methodist Church, I am opposed to Tennessee's block grant proposal  that will open the door for cutting the number of people covered, cutting how many services are provided and cutting  how much the state pays hospitals, doctors and other providers.    Not long ago, I was one of those vulnerable single‐moms with two children who could only afford a catastrophic health  plan that did not cover prescriptions. I finally have health insurance that meets my needs, including prescriptions.    As for my extended family this is not the case for my family members. I have one sibling, who lives in Tennessee and  suffers with a chronic disease that causes her to have multiple surgeries a year. If she lost any part of her coverage, she  would not be able to pay for her treatments.  Currently, she also has to ration her medication because she meets her  TennCare limit each month.    Tennessean's healthcare must come first above all else everything.  Then our rural hospitals hospitals can stay open.  More people will enter the workforce. And, God's people will live fruitful and full lives.    What we need is Medicaid Expansion and we need it now.  Block Grants will take lives; expansion will save lives.    I urge you to stop chasing Block Grants and start the process to expand Medicaid.  It's just the right thing to do.     _________________________________________    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rev. Merrilee Wineinger  1381 Drakes Creek Rd  Hendersonville, TN 37075‐8519 merrilee.wineinger@gmail.com  7 Jonathan Reeve From: Sent: To: Subject: MAlex217@everyactioncustom.com on behalf of Martha Alexander Friday, October 18, 2019 11:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Martha Alexander  7823 Gleason Dr  Knoxville, TN 37919‐6814 MAlex217@aol.com  8 Jonathan Reeve From: Sent: To: Subject: blheflin@everyactioncustom.com on behalf of Barbara Heflin Friday, October 18, 2019 11:32 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I am opposed to the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am very opposed to the proposal to change federal funding for TennCare into a “block grant.” This proposal would  cause immense harm and jeopardize coverage for vulnerable Tennesseans.     I am a retired health care social worker and know the critical importance of TennCare/Medicaid and am frightened for  those who need health care should the change be made to a block grant.  I have seen the critical need for TennCare  Medicaid and the proposed changes could cut back on benefits currently being received without any federal approval.     This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these  vulnerable populations. The state could eliminate or restrict services like physical therapy, hospice, and transplant  coverage without normal federal oversight – and arbitrarily limit who gets them. The proposal could also cut back on  core health care services like hospital care, without federal approval or public notice, and exclude coverage of the most  effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is flawed, cannot be fixed. It goes against the goals and purpose of the Medicaid program. We respectfully  urge you not to go forward with this harmful proposal.    Sincerely,  Barbara Heflin  1980 Norwood Trl  Clarksville, TN 37043‐4635 blheflin@gmail.com  9 Jonathan Reeve From: Sent: To: Subject: Debra.Transue@everyactioncustom.com on behalf of Debra Transue Friday, October 18, 2019 11:36 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Debra Transue  140 E Swan St  Centerville, TN 37033‐1445 Debra.Transue@ascension.org  10 Jonathan Reeve From: Sent: To: Subject: sawuschfamiky@everyactioncustom.com on behalf of Suzanne Sawusch Friday, October 18, 2019 11:22 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Please do not hurt the people on TN by allowing this block grant to pass.   I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Suzanne Sawusch  9249 Wet Mill Creek Rd  Celina, TN 38551‐5644 sawuschfamiky@gmail.com  11 Jonathan Reeve From: Sent: To: Subject: heididavis2011@everyactioncustom.com on behalf of Heidi Davis Friday, October 18, 2019 11:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Turning TNCare into a block grant is a mistake.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     States need the flexibility to grow and shrink their programs year to year. This will add undue burden to the state and  hardship for TN residents. Limiting services that people would qualify for if they lived in a different state is a one way  ticket for TN to race to the bottom on the health of it's residents.     The state of healthcare in this state is already meager. Don't let block Granting make it worse.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Heidi Davis  1122 Opekiska St  Erwin, TN 37650  heididavis2011@gmail.com  12 Jonathan Reeve From: Sent: To: Subject: chem2591@everyactioncustom.com on behalf of Dennis Golob Friday, October 18, 2019 11:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Oppose Medicaid Block Grant Proposal   Dear Gabe Roberts,    Tennessee ranks in the bottom ten in nearly all areas when compared to other states in Health.  We nearly HELP, not savings. We were the last state in the union to pass a law promoted by Ronald Reagan to help  severely handicapped children.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dennis Golob  Kingsport, TN 37660  chem2591@gmail.com  13 Jonathan Reeve From: Sent: To: Subject: emrflute@everyactioncustom.com on behalf of Em R. Friday, October 18, 2019 11:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Em R.  Atlanta, GA 30309  emrflute@gmail.com  14 Jonathan Reeve From: Sent: To: Subject: abp0511@everyactioncustom.com on behalf of Ashley Phillips Friday, October 18, 2019 12:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ashley Phillips  337 Bay St  Mount Carmel, TN 37645‐3902  abp0511@charter.net  15 Jonathan Reeve From: Sent: To: Subject: kpsmith126@everyactioncustom.com on behalf of Kathy Smith Friday, October 18, 2019 1:36 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I have a brother that is on TennCareOpposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathy Smith  126 Chappell Rd  Surgoinsville, TN 37873‐5300 kpsmith126@tahoo.com  16 Jonathan Reeve From: Sent: To: Subject: abat706@everyactioncustom.com on behalf of Joseph Collins Friday, October 18, 2019 1:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joseph Collins  Kingsport, TN 37662  abat706@aol.com  17 Jonathan Reeve From: Sent: To: Subject: kpsmith126@everyactioncustom.com on behalf of Kathy Smith Friday, October 18, 2019 1:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathy Smith  Surgoinsville, TN 37873  kpsmith126@yahoo.com  18 Jonathan Reeve From: Sent: To: Subject: pfcasey@everyactioncustom.com on behalf of Paula Casey Friday, October 18, 2019 1:43 AM PUBLICE NOTICE TENNCARE [EXTERNAL] OPPOSITION to Medicaid Block Grant Proposal   Dear Gabe Roberts,    I OPPOSE the proposal to radically change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” This proposal is absurd and unnecessary. Republicans are  philosophically against providing for the commonweal, especially with health care. I remember the Republican fight  against Medicare. They were wrong then and they're wrong now.    Of course you know that Medicaid was created to help children, people with disabilities, pregnant women, and other  vulnerable Americans get vital health coverage they need.     This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these  vulnerable populations. The state could eliminate or restrict services like physical therapy, hospice, and transplant  coverage without normal federal oversight – and arbitrarily limit who gets them. The proposal could also cut back on  core health care services like hospital care, without federal approval or public notice, and exclude coverage of the most  effective prescription drugs.     TennCare needs MORE accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this HARMFUL proposal. Why do you want people to suffer?    Sincerely,  Ms. Paula Casey  99 N Main St Apt 901 Memphis, TN 38103‐5005 pfcasey@bellsouth.net  19 Jonathan Reeve From: Sent: To: Subject: mjcunningham2@everyactioncustom.com on behalf of Melody Cunningham Friday, October 18, 2019 3:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Melody Cunningham  900 Harbor Bend Rd  Memphis, TN 38103‐0803 mjcunningham2@comcast.net  20 Jonathan Reeve From: Sent: To: Subject: Steven Derer Friday, October 18, 2019 5:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Steven Derer   101 Tanasi View  Loudon, TN 37774   21 Jonathan Reeve From: Sent: To: Subject: cashsouth@everyactioncustom.com on behalf of Patricia Cash Friday, October 18, 2019 6:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grants will cause deaths among our children ,poor,handicapped and seniors   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patricia Cash  Nashville, TN 37205  cashsouth@aol.com  22 Jonathan Reeve From: Sent: To: Subject: kpsmith126@everyactioncustom.com on behalf of Kathy Smith Friday, October 18, 2019 2:09 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Brother on TennCare   Dear Gabe Roberts,    I have a brother that is on TennCare. Since birth he is not mentally able to care for himself and has to have 24 hour  supervision. He also suffers from crohns disease. Our state has proved to us unfortunately that it definitely needs  Federal Oversight. Our healthcare is a disaster and we ask that you don’t allow them to make these changes that would  give them more control and hurt lots of our people that truly need assistance.  I am opposed to the proposal to radically  change Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into  a “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Kathy Smith  126 Chappell Rd  Surgoinsville, TN 37873‐5300 kpsmith126@yahoo.com  23 Jonathan Reeve From: Sent: To: Subject: hillise@everyactioncustom.com on behalf of Erin Hillis Friday, October 18, 2019 6:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Vulnerable Tennesseans ‐including our children‐ need more help, not less. I am opposed to the proposal to radically  change Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into  a “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Erin Hillis  Memphis, TN 38119  hillise@rhodes.edu  24 Jonathan Reeve From: Sent: To: Subject: sjzachau@everyactioncustom.com on behalf of Sharon Zachau Thursday, October 17, 2019 8:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am deeply concerned about allowing Tennessee's Medicaid program to a block grant model.   This proposal would  cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Without federal oversight, a block grant model could allow funds to be spent and "lost" without the accountability  necessary.       Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sharon Zachau  45 Carpenter Close  Sewanee, TN 37375‐2010 sjzachau@gmail.com  25 Jonathan Reeve From: Sent: To: Subject: dellacrusca@everyactioncustom.com on behalf of Bill Levine Thursday, October 17, 2019 8:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Bill Levine  Murfreesboro, TN 37130  dellacrusca@yahoo.com  26 Jonathan Reeve From: Sent: To: Subject: scheatham1@everyactioncustom.com on behalf of Susan Cheatham Thursday, October 17, 2019 8:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am strongly opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans. Gov. Lee promised 21st healthcare solutions for Tennessee while  campaigning. This proposal is a backwards solution and will hurt our children, our low income and disabled citizens. We  have also been insulted by The governor who has said if we understood the proposal, we would support it.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.    Tennessee ranks third in the nation for uninsured citizens and this proposal will further reduce the number of covered  Tennesseans. Access to care has also declined as we lead the nation in rural hospital closings. To suggest that services,  coverage and access will improve under the block grant is folly.      This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.      Sincerely,      Susan Cheatham  Registered Voter  Davidson County    Address:  1821 Cedar Ln. Nashville TN 37212 Scheatham1@bellsouth.net    Sincerely,  Susan Cheatham  Nashville, TN 37212  scheatham1@bellsouth.net  27 Jonathan Reeve From: Sent: To: Subject: robertharris1956@everyactioncustom.com on behalf of Bob Harris Thursday, October 17, 2019 8:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] My stepdaughter is receiving TennCare benefits and it is helping her stabilize her life and meet her healthcare needs. I do not want it to be changed.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Bob Harris  1829 Dunroamin Ln  Fayetteville, TN 37334‐3728 robertharris1956@icloud.com  28 Jonathan Reeve From: Sent: To: Subject: julie.a.fitzgerald.7@everyactioncustom.com on behalf of Julie Thacker Thursday, October 17, 2019 9:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     Tennessee is the "healthcare capital of the world," and yet our health outcomes are abysmal compared to the rest of the  nation. Many in the state are already suffering the losses of rural hospitals and the block grant would only further  devastate poor and rural communities.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Julie Thacker  5114 Kincannon Dr  Nashville, TN 37220‐2004 julie.a.fitzgerald.7@gmail.com  29 Jonathan Reeve From: Sent: To: Subject: beverlyheadley@everyactioncustom.com on behalf of Beverly Headley Thursday, October 17, 2019 9:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a RN and Certified Case Manager, I am opposed to the proposal to radically change Tennessee’s Medicaid partnership  with the federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Beverly Headley  1406 Hanson Dr  Franklin, TN 37067‐8666  beverlyheadley@gmail.com  30 Jonathan Reeve From: Sent: To: Subject: missbb9@everyactioncustom.com on behalf of Phyllis Silcox Thursday, October 17, 2019 9:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposition Comment Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.       I oppose Block Grant.   Have a disabled sister who would loose benefits for health care and supplies that she needs for  survival.   Please do not pass this proposal.    Sincerely,  Phyllis Silcox  2624 Bay St  Bristol, TN 37620‐1847  missbb9@yahoo.com  31 Jonathan Reeve From: Sent: To: Subject: Amyliza de Jesus Thursday, October 17, 2019 9:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Amyliza de Jesus   4613 Brown Leaf Drive  Green Hill, TN 37138   32 Jonathan Reeve From: Sent: To: Subject: karin.moore@everyactioncustom.com on behalf of Karin Moore Thursday, October 17, 2019 9:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Please don't sacrifice my family for a Medicaid Block Grant!   Dear Gabe Roberts,    I am opposed to the plan to change Tenncare into a block grant. I have disabling lupus and my two children have autism.  I need Tenncare for my survival and my boys need Tenncare to be able to move towards becoming contributing  members of society. If any of our benefits were cut, as I am sure they would be under a block grant, it would be life  altering for us. Please do not sacrifice our well being just to change to a poor funding formula through block grants. Keep  the Tenncare safeguards in place and keep insuring people which ensures they can have meaningful, full lives.    Sincerely,  Karin Moore  Memphis, TN 38135  karin.moore@comcast.net  33 Jonathan Reeve From: Sent: To: Subject: cynthiapagevernon@everyactioncustom.com on behalf of Cynthia Page Thursday, October 17, 2019 9:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I write with regard to the “block grant” proposal.  The representatives I have spoken with defend the motion by  providing an example of someone misusing the Medicaid system or simply by saying “Let’s just give it a try.”  To me this  is unacceptable.  People in need will be unserved, underserved, and will die because a bunch of people got together to  throw a dart and see what will happen with a block grant grant.  Federal oversight, accountability, patient safeguards...these are all important features for a program to work well.  I urge you to stop this notion and focus on something that will work.      Sincerely,  Cynthia Page  2216 Winder Cir  Franklin, TN 37064‐4935  cynthiapagevernon@gmail.com  34 Jonathan Reeve From: Sent: To: Subject: carolyngibbons1@everyactioncustom.com on behalf of Carolyn Gibbons Thursday, October 17, 2019 9:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant will not help those in desperate need. The prescription part is a joke. Alan Levine in all over this and does not have the people at the heart of this. Do not do the Block Grant. We need oversight with the FTC on our health care.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Carolyn Gibbons  1620 Leaside Dr  Kingsport, TN 37664‐2730 carolyngibbons1@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: keiakiwi@everyactioncustom.com on behalf of Keia Keeling Thursday, October 17, 2019 9:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Keia Keeling  Johnson City, TN 37615  keiakiwi@gmail.com  36 Jonathan Reeve From: Sent: To: Subject: keiakiwi@everyactioncustom.com on behalf of Kim Loveless Thursday, October 17, 2019 9:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kim Loveless  Johnson City, TN 37615  keiakiwi@gmail.com  37 Jonathan Reeve From: Sent: To: Subject: keiakiwi@everyactioncustom.com on behalf of Charles Keeling Thursday, October 17, 2019 9:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Charles Keeling  Johnson City, TN 37615  keiakiwi@gmail.com  38 Jonathan Reeve From: Sent: To: Subject: ericaalex3@everyactioncustom.com on behalf of Erica Alexander Thursday, October 17, 2019 9:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Erica Alexander  Chuckey, TN 37641  ericaalex3@gmail.com  39 Jonathan Reeve From: Sent: To: Subject: thedanicook@everyactioncustom.com on behalf of Dani Cook Thursday, October 17, 2019 9:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dani Cook  Kingsport, TN 37660  thedanicook@gmail.com  40 Jonathan Reeve From: Sent: To: Subject: lazymazie@everyactioncustom.com on behalf of Mary Ann Crowe Thursday, October 17, 2019 9:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal Too Big a Gamble   Dear Gabe Roberts,    I have two adult children with disabilities, both need on‐going medical care which they currently receive through Tenn  Care.  Without Tenn Care the emergency room would be their only option for health care.  Tenn Care enables them to  keep chronic conditions under control, preventing further deterioration.  If they should lose Tenn Care due to cost  cutting they could no longer afford their medications.    For 8 years I volunteered with a non‐profit working with low income residents to help them with utilities, rent, food, and  other necessities.  During interviews with most of them it was apparent that without Tenn Care they would have no on‐ going health care to treat their chronic conditions.  They would not be able to afford their medications.  While many  charitable organizations help these people, there is no way they could pay hospital or doctor bills ‐ they quickly would go  broke trying to do so.      Cumberland County's hospital appears to be solvent, but many surrounding counties are losing their hospitals. Residents  affected by those closures must travel some distance to an emergency room.  Doing so endangers their health and  possibly their lives.  If hospitalization outside their home county is required it puts a considerable burden on them and  their families.  Expanding Medicaid has enabled many other states to avoid the hospital closures that currently plague  Tennessee.     While virtually all Republican governors who chose to expand Medicaid agree it was the right thing to do for their  citizens, it appears that some of our state leaders want block granting of Tennessee’s healthcare to allow them to  remove  $2 billion out of Tennessee’s health care system.  Diverting funds from the health care system is the absolute  last thing our state should be considering.  Our residents deserve better than that.  As Ohio Governor Kasich said “If they  don’t get coverage, they end up in the emergency room, they end up sicker, more expensive, I mean, we pay one way or  the other,” “And so this has been a good thing for Ohio.”  Voters in red states with health care issues on their ballots  voted to expand Medicaid.  Majorities of Americans now agree that everyone should be able to go to the doctor or  hospital without going bankrupt.      In a rural state that places great emphasis on family values, ours is full of residents who are uninsured.  Being able to  care for one’s health and the health of their family epitomizes a family value.    Taking a chance on block granting health care for needy Tennessee residents seems like too big a gamble for us to take.   I respectfully ask that you abandon this gamble and expand Medicaid in our state, an option that has proved very  successful in states with other Republican governors.     Sincerely,      Mary Ann Crowe  Crossville, TN    Sincerely,  41 Mrs. Mary Ann Crowe  1903 Claysville Rd  Crossville, TN 38571‐7302 lazymazie@frontiernet.net  42 Jonathan Reeve From: Sent: To: Subject: tiny.paws.sanctuary@everyactioncustom.com on behalf of JAMIE FARRIS Thursday, October 17, 2019 9:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am very much opposed to the block grant proposal. I believe that state legislators are systematically taking control of  our healthcare and leaving the poorest, most vulnerable Tennesseans without medical care coverage.     I am one of the peaceful protesters fighting to stop a state sanctioned medical monopoly in NE TN called Ballad Health.  Ballad was created, thanks to a unique COPA passed by TN legislators, that protects Ballad from anti‐trust laws. While it  was said that the COPA would have careful oversight, it has not. Because of that, we have little access to quality care and  the cost to the patient has gone up significantly. If not for medicaid/TNCare and Medicare, many of us would not receive  care at all.     TN had the opportunity to expand medicaid with the federal government covering 100 percent of the cost and giving up  to 280000 Tennesseans coverage.  Tennessee refused to accept it unlike most other states. The reason is still unclear to  me.     Now the governor is supporting block grants. With these grants,  the state will continue to get funding from the federal  government as membership grows, but if TennCare spends less than the federal government gives it, Tennessee state  government can keep half of the extra money. This means that state government, which already provides among the  stingiest benefits to the working poor, will have an incentive to cut those benefits even further.     It seems very clear that the State of TN has no concern for its poor citizens. We in East TN are already experiencing what  happens when the state is given the power to undermine medical coverage and quality of care.     This three step process needs to be stopped in its tracks.                 Sincerely,  JAMIE FARRIS  109 Pine St  Church Hill, TN 37642‐3852  tiny.paws.sanctuary@gmail.com  43 Jonathan Reeve From: Sent: To: Subject: ericaalex3@everyactioncustom.com on behalf of Erica Alexander Thursday, October 17, 2019 9:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Erica Alexander  Chuckey, TN 37641  ericaalex3@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: nikkilonza@everyactioncustom.com on behalf of Nicole Lonza Thursday, October 17, 2019 10:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.      Do not alter TennCare. Growing up in a broken home, full of drugs and unpaid Bill's, TennCare is the only reason we had  health care access as children.     Sincerely,  Nicole Lonza  2221 Nolensville Pike  Nashville, TN 37211‐2043 nikkilonza@gmail.com  45 Jonathan Reeve From: Sent: To: Subject: WILLIAM BELVIN Thursday, October 17, 2019 4:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant proposal Governor Lee thinks many of us have been misinformed about his efforts to change Tennessee's Medicaid program. Perhaps we have been misinformed in that many of us believed he would put his core religious values into practice --caring for the poor vs. rich. I have insurance but I will be affected. How? My church has an Acape Center that we support entirely from church funds. I know we will have more clients in desperate situations because more people will have to make the choice of medication vs. food. This is a choice that these clients should not have to make when they or a member of their family needs medical help. Our state's future is affected by children not receiving proper health care. As a former teacher and a parent of adopted children, I have observed the negative effects of poor health care on the education and growth of a child. There is no easy solution to the problem but refusing to expand Medicare because of "political pride" is absurd. Debra Belvin 46 Jonathan Reeve From: Sent: To: Subject: sazzysage59@everyactioncustom.com on behalf of Dena Price Thursday, October 17, 2019 4:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dena Price  257 Hubbard Rd  Crossville, TN 38572‐1979 sazzysage59@gmail.com  47 Jonathan Reeve From: Sent: To: Subject: mdurnin489@everyactioncustom.com on behalf of Marjorie Durnin Thursday, October 17, 2019 4:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marjorie Durnin  Jacksonville, NC 28546  mdurnin489@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: ann.ercelawn@everyactioncustom.com on behalf of Ann Ercelawn Thursday, October 17, 2019 4:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  The main goal of this proposal seems to be to save money, not to provide health services.     Sincerely,  Ann Ercelawn  3611 Saratoga Dr  Nashville, TN 37205‐2539 ann.ercelawn@gmail.com  49 Jonathan Reeve From: Sent: To: Subject: shelliap@everyactioncustom.com on behalf of Shellia Powell Thursday, October 17, 2019 4:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Shellia Powell  662 Doak Rd  Manchester, TN 37355‐7571  shelliap@hotmail.com  50 Jonathan Reeve From: Sent: To: Subject: dick206@everyactioncustom.com on behalf of Dick Williams Thursday, October 17, 2019 4:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dick Williams  2319 Selma Ave  Nashville, TN 37214‐2110 dick206@aol.com  51 Jonathan Reeve From: Sent: To: Subject: bonnieubarnes@everyactioncustom.com on behalf of Bonnie Barnes Thursday, October 17, 2019 5:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a school librarian in Memphis. I’m opposed to the proposal to radically change Tennessee’s Medicaid partnership  with the federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid.     I’m a school librarian and I think it’s a terrible waste of opportunity to try to use block grants instead of accepting the  funds that we have access to. We’ve already lost a tremendous amount of money that could have helped the people of  our state because of the shortsightedness of our state legislators.    Sincerely,  Ms. Bonnie Barnes  8259 Byre Hollow Cv  Cordova, TN 38018‐7225 bonnieubarnes@aol.com  52 Jonathan Reeve From: Sent: To: Subject: Cassie Diaz-Bello Thursday, October 17, 2019 5:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Cassie Diaz‐Bello   103 Okema Lane  Loudon, TN 37774   53 Jonathan Reeve From: Sent: To: Subject: noodlenash@everyactioncustom.com on behalf of Denise Thurman Thursday, October 17, 2019 5:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Denise Thurman  404 Raines St  Plainfield, IN 46168‐1658 noodlenash@yahoo.com  54 Jonathan Reeve From: Sent: To: Subject: noodlenash@everyactioncustom.com on behalf of Denise Thurman Thursday, October 17, 2019 5:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I have paralyzed relative depending on TN medicaid. I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Denise Thurman  404 Raines St  Plainfield, IN 46168‐1658 noodlenash@yahoo.com  55 Jonathan Reeve From: Sent: To: Subject: won.kim4989@everyactioncustom.com on behalf of Valerie Kim Thursday, October 17, 2019 5:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Valerie Kim  Nashville, TN 37235  won.kim4989@gmail.com  56 Jonathan Reeve From: Sent: To: Subject: patrick.s.jeon@everyactioncustom.com on behalf of Patrick Jeon Thursday, October 17, 2019 5:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patrick Jeon  Nashville, TN 37240  patrick.s.jeon@vanderbilt.edu  57 Jonathan Reeve From: Sent: To: Subject: jacquelineoh1228@everyactioncustom.com on behalf of Jacqueline Oh Thursday, October 17, 2019 6:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Jacqueline Oh  Nashville, TN 37235  jacquelineoh1228@yahoo.com  58 Jonathan Reeve From: Sent: To: Subject: mjonesmgmt@everyactioncustom.com on behalf of Mark Jones Thursday, October 17, 2019 6:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I Say No to the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, I am the father of a 28 year old daughter who is profoundly physically and cognitively disabled.  She can do  NOTHING for herself. She is tube fed, has a history of seizures, has had major abdominal surgeries, requires constant  care and yet, she is probably the most cheerful member of my family.  My wife and I, with support from medicaid and  Tenncare have managed to raise Rachel and  two other beautiful and prosperous children. Rachel has made us all better  people.      Recently Tenncare/Amerigroup slashed our skilled nursing care resource and replaced most of it with unskilled nursing  assistants who are not legally allowed to perform most of the care that Rachel gets daily. In doing so they have  endangered Rachel, and effected my wife and I's ability to work  ... and pay taxes.      With these cuts, and hundreds more like them across the state,  Tenncare/Amerigroup has shown it's true intent should  the proposed block grant initiative succeed. The proposed block grant has few guidelines that would protect Tennesee's  most vulnerable from vicious and inhumane cuts in services that not only protect those at risk, but also help to maintain  family structures and allow other siblings and the parents themselves to grow into productive taxpaying members of  society.      This block grant cannot be allowed to happen. I believe it is simply another mechanism to reduce tax rates for those at  the top of the economic food chain.      I SAY NO      Mark Jones        Sincerely,  Mark Jones  Franklin, TN 37064  mjonesmgmt@comcast.net  59 Jonathan Reeve From: Sent: To: Subject: christychung9@everyactioncustom.com on behalf of Christy Chung Thursday, October 17, 2019 6:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Christy Chung  Nashville, TN 37235  christychung9@gmail.com  60 Jonathan Reeve From: Sent: To: Subject: mitzipearson19@everyactioncustom.com on behalf of Mitzi Pearson Thursday, October 17, 2019 6:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.     How much more are Tennesseans going to have to suffer.  They have ruined the healthcare in NE Tennessee and now  lets take away TN Care for children and the elderly who have no voice.  Governor Lee has let Ballad Health ruin our  healthcare, It's time to say no to the block grants.   Sincerely Mitzi Pearson    Sincerely,  Mitzi Pearson  400 Neal Ln  Kingsport, TN 37660‐6238  mitzipearson19@gmail.com  61 Jonathan Reeve From: Sent: To: Subject: Alex Birnbaum Thursday, October 17, 2019 6:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Alex Birnbaum   818 N Bragg Ave  Lookout Mountain, TN 37350   62 Jonathan Reeve From: Sent: To: Subject: horsenround@everyactioncustom.com on behalf of Lisa Jones Thursday, October 17, 2019 6:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I SAY NO    Sincerely,  Lisa Jones  Franklin, TN 37064  horsenround@comcast.net  63 Jonathan Reeve From: Sent: To: Subject: jcjackson333@everyactioncustom.com on behalf of Conniece Jackson Thursday, October 17, 2019 6:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Too few practices will accenptTennCare for payment for services and/or medication , this would just make my being able to get help, more difficult, My income is already so low, I NEED REGULAR MEDICARE not this "block" rip-off.!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Conniece Jackson  2113 Fleming Rd  Clarksville, TN 37043‐5062 jcjackson333@gmail.com  64 Jonathan Reeve From: Sent: To: Subject: mgreentn@everyactioncustom.com on behalf of Mary Green Thursday, October 17, 2019 6:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] No to Medicaid Block Grant   Dear Gabe Roberts,    I attended the Memphis public comments meeting on October 15th regarding the the proposal to change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” I  zOPPOSE this proposal because it would cause immense harm and jeopardize coverage for vulnerable Memphians, as  clearly stated by everyone who spoke at that meeting.       Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program. I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Mary Green  1765 Dickens Cv  Germantown, TN 38139‐3600 mgreentn@comcast.net  65 Jonathan Reeve From: Sent: To: Subject: DianaW11@everyactioncustom.com on behalf of Diana Gray Thursday, October 17, 2019 6:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Diana Gray  828 Kendall Dr  Nashville, TN 37209‐4512 DianaW11@aol.com  66 Jonathan Reeve From: Sent: To: Subject: Litlhypurr@everyactioncustom.com on behalf of Suzanne Ford Thursday, October 17, 2019 7:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Suzanne Ford  Blountville, TN 37617  Litlhypurr@netzero.com  67 Jonathan Reeve From: Sent: To: Subject: HDMotors@everyactioncustom.com on behalf of Denver Ford III Thursday, October 17, 2019 7:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr Denver Ford III  Blountville, TN 37617  HDMotors@centurylink.net  68 Jonathan Reeve From: Sent: To: Subject: shstapleton17@everyactioncustom.com on behalf of Sarah Stapleton Thursday, October 17, 2019 7:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sarah Stapleton  Sewanee, TN 37375  shstapleton17@gmail.com  69 Jonathan Reeve From: Sent: To: Subject: delayna@everyactioncustom.com on behalf of Delayna Whitson Thursday, October 17, 2019 7:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Delayna Whitson  Kingsport, TN 37663  delayna@gmail.com  70 Jonathan Reeve From: Sent: To: Subject: rjdreamsong@everyactioncustom.com on behalf of Richard Johnston Thursday, October 17, 2019 7:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Richard Johnston  300 Sycamore Dr Apt A7 Franklin, TN 37064‐2339 rjdreamsong@yahoo.com  71 Jonathan Reeve From: Sent: To: Subject: heather.lupinek@everyactioncustom.com on behalf of Heather Wolf Thursday, October 17, 2019 12:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Heather Wolf  Portland, TN 37148  heather.lupinek@yahoo.com  72 Jonathan Reeve From: Sent: To: Subject: wilsonsm86@everyactioncustom.com on behalf of Stephanie Wilson Thursday, October 17, 2019 11:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Stephanie Wilson  6416 Harrison Pike  Chattanooga, TN 37416‐1413 wilsonsm86@gmail.com  73 Jonathan Reeve From: Sent: To: Subject: Brenda Price Thursday, October 17, 2019 12:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Brenda Price   1500 Homeplace Ct  Clarksville, TN 37043   74 Jonathan Reeve From: Sent: To: Subject: amodernbergeron@everyactioncustom.com on behalf of Drue Zaharis Thursday, October 17, 2019 12:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a daughter of elderly Tennessee parents and a Tennessean myself approaching retirement age, I am opposed to the  proposal to radically change Tennessee’s Medicaid partnership with the federal government by converting federal  funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     Medicaid is a beautiful idea ‐ created to help children, people with disabilities, pregnant women, and other vulnerable  Americans get vital health coverage they need. This proposed change goes against the objectives of Medicaid because it  gives Tennessee new authority to cut services for these vulnerable populations. The state could eliminate wholesale or  restrict services like physical therapy, hospice, and transplant coverage without normal federal oversight – and  arbitrarily limit who gets them when in reality these services need to expand not contract. The proposal could also cut  back on core health care services like hospital care, without federal approval or public notice, and exclude coverage of  the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. Without oversight and transparency who will represent the most in need of  care? This proposal invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Drue Zaharis  7 Ridgeside Rd  Chattanooga, TN 37411‐1828 amodernbergeron@gmail.com  75 Jonathan Reeve From: Sent: To: Subject: aburns.lpc@everyactioncustom.com on behalf of Amanda Burns Thursday, October 17, 2019 12:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a licensed mental health provider, I am opposed to the proposal to radically change Tennessee’s Medicaid  partnership with the federal government by converting federal funding for TennCare into a “block grant.” This proposal  would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amanda Burns  Knoxville, TN 37917  aburns.lpc@gmail.com  76 Jonathan Reeve From: Sent: To: Subject: bobridley1945@everyactioncustom.com on behalf of Robert Ridley Thursday, October 17, 2019 12:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a Licensed Professional Counselor and Mental Health Service Provider in Tennessee. Over 17 years of work with  mental health agencies and in private practice, more than half of my clients have been Tenn Care patients. I have  personally seen that this vital coverage has saved my clients' lives and preserved their ability to work and to care for  their personal needs and for their families. I have also seen the devastating effect when some of my clients have lost  their Tenn Care coverage.      Several of my clients who were suffering severe and chronic persistent mental illness were thrown into great risk. One  who could no longer get an essential psychotropic medication, a generic formula costing very little, became unstable  over several months and ultimately was involved in a suicidal standoff with police and emergency medical responders.  This nearly ended in violent  gunfire death and it cost the city a lot of money and resources to defuse.     Another client who lost Tenn Care was no longer able to work due to severe anxiety and she lost her job  and her  apartment in the aftermath of that cancellation.  I had not seen her for several years, but recently met her in town and  learned that she had been homeless in the years since then and had nearly died more than once. I could name more  instances, but my point is that this is a vital and life‐saving service that should not be taken away from our most  vulnerable citizens.    I have been raising a grand‐child for 14 years, and we have another family member who is also on Tenn Care. For these  two family members, Tenn Care has been their link to self care and wellness.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for Tenn Care into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Tenn Care needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    77 Sincerely,     Robert M Ridley, LPC/MHSP          Sincerely,  Mr. Robert Ridley  3651 Shipley Rd  Cookeville, TN 38501‐7719 bobridley1945@gmail.com  78 Jonathan Reeve From: Sent: To: Subject: li51@everyactioncustom.com on behalf of Linda Carr Thursday, October 17, 2019 1:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Linda Carr  113 Fairway Dr  Crossville, TN 38558‐7103 li51@hotmail.com  79 Jonathan Reeve From: Sent: To: Subject: 3beesbox@everyactioncustom.com on behalf of Debbie Shulman <3beesbox@everyactioncustom.com> Thursday, October 17, 2019 12:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Personally, my children and I are on Tenncare /United Healthcare. Thank God we are healthy. We are law abiding  citizens, my husband is a disabled vet and this is the only insurance we can get at the moment for a family of five.     I can’t imagine what this will Do to the applicants who are like us.     One of constitutional rights is the pursuit of happiness. One can not pursue happiness if their life is shortened because  they can’t afford a $400.00 prescription or $1000.00 MRI. It is disgraceful and an eminent act of human rights. People  are not like the senators and representatives who come from rich families who have access to healthcare that the  average or below average person can not obtain. You arE basically killing people.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Debbie Shulman  Crossville, TN 38572  3beesbox@gmail.com  80 Jonathan Reeve From: Sent: To: Subject: mwmjones@everyactioncustom.com on behalf of Martha Jones Thursday, October 17, 2019 1:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Martha Jones  Nashville, TN 37205  mwmjones@pacbell.net  81 Jonathan Reeve From: Sent: To: Subject: topnotchsoc@everyactioncustom.com on behalf of Jennifer Randolph Thursday, October 17, 2019 1:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  This goes against everything thing that I as a Christian believe in. It is not how you fix our problems. What happened to  the Tennessee Volunteer state that helps their neighbor?!    Sincerely,  Jennifer Randolph  265 Sugar Hollow Trl  Piney Flats, TN 37686‐3230 topnotchsoc@aol.com  82 Jonathan Reeve From: Sent: To: Subject: laurenlc347@everyactioncustom.com on behalf of Lauren Fenty Thursday, October 17, 2019 1:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Growing up beneath the poverty line, TennCare provided vital healthcare services for me and my siblings. I will forever  appreciate that, and the opportunities good health created for me to improve my circumstances as I grew. I want to see  these services continue to be provided for those who so desperately need them. Thank you for your time and  consideration.     Sincerely,  Lauren Fenty  Normandy, TN 37360  laurenlc347@gmail.com  83 Jonathan Reeve From: Sent: To: Subject: Jeanette Opheim Thursday, October 17, 2019 1:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Jeanette Opheim   1697 Brockton Lane  Nashville, TN 37221   84 Jonathan Reeve From: Sent: To: Subject: Kristenmgrimm@everyactioncustom.com on behalf of Kristen Grimm Thursday, October 17, 2019 1:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Kristen Grimm  303 Fitzgerald St  Franklin, TN 37064‐5098 Kristenmgrimm@gmail.com  85 Jonathan Reeve From: Sent: To: Subject: patlovesface@everyactioncustom.com on behalf of Pat Rosario Thursday, October 17, 2019 1:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Enact universal healthcare, or leave Tenncare alone. It is a life saver for countless families. We do not need to make it  more inefficient.     Sincerely,  Pat Rosario  Tullahoma, TN 37388  patlovesface@gmail.com  86 Jonathan Reeve From: Sent: To: Subject: margie.gray13@everyactioncustom.com on behalf of Marjorie Gray Thursday, October 17, 2019 1:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    As a nurse, I have seen the devastating consequences of being under insured or uninsured. I have taken care of cancer  patients who have had to file bankruptcy just to afford the lifesaving chemo for their spouse or child. I have taken care  of those in their last days, being kept comfortable as they say goodbye to friends and loved ones. It was through hospice  that they were able to afford the nursing care and medications to keep them in a some what comfortable state. Without  Medicare hospice patients would have these valuable services. Those patients and their families would be left to the  painful, long, and heartbreaking process of death. How would you decide who gets hospice care or how much care they  receive? And how is it fair to decide those decisions? If you support and uphold this proposal, you are deciding that  some people are more deserving of a peaceful death then others.    Sincerely,  Marjorie Gray  2202 Traemoore Village Way Nashville TN 37209  Nashville, TN 37209 margie.gray13@gmail.com  87 Jonathan Reeve From: Sent: To: Subject: zach_riggs@everyactioncustom.com on behalf of Zachary Riggs Thursday, October 17, 2019 1:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Zachary Riggs  200 Devrow Ct  Franklin, TN 37064‐6865  zach_riggs@yahoo.com  88 Jonathan Reeve From: Sent: To: Subject: mholzer@everyactioncustom.com on behalf of Marie Holzer Thursday, October 17, 2019 2:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am disgusted by the proposal. This proposal will only perpetuate the already longstanding inequalities that have cost  this country trillions of dollars. The idea that this could be passed is not only threatening to me, my neighbors, and my  family, but to the state of Tennessee itself. Without preventive care and quality care for that matter, we are also  perpetuating the costs of more intensive care for diseases that could have been managed with proper and immediate  care.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.        Sincerely,  Marie Holzer  214 Garwood Dr  Nashville, TN 37210‐5116 mholzer@vols.utk.edu  89 Jonathan Reeve From: Sent: To: Subject: ehholmes@everyactioncustom.com on behalf of Elizabeth Holmes Thursday, October 17, 2019 2:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.”      TN has some of the most daunting challenges facing any state, including being among the worst in declining insurance  coverage of children and rising rate of rural hospital closures. The proposal could also cut back on core health care  services like hospital care, without federal approval or public notice, and exclude coverage of the most effective  prescription drugs.    We are only as strong as our weakest links.  Therefore we need to secure decent healthcare for our most vulnerable.      Sincerely,  Mrs. Elizabeth Holmes  916 Ashford Ct  Brentwood, TN 37027‐8715 ehholmes@comcast.net  90 Jonathan Reeve From: Sent: To: Subject: gail.stover@everyactioncustom.com on behalf of Barbara Stover Thursday, October 17, 2019 2:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Barbara Stover  360 Sliger Rd  Cookeville, TN 38506‐5914 gail.stover@gmail.com  91 Jonathan Reeve From: Sent: To: Subject: hodgessuzanne900@everyactioncustom.com on behalf of Suzanne Hodges Thursday, October 17, 2019 2:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Suzann Hodges    Sincerely,  Suzanne Hodges  1599 John Ridge Dr  Collierville, TN 38017‐8659 hodgessuzanne900@gmail.com  92 Jonathan Reeve From: Sent: To: Subject: Carrie Benchea Thursday, October 17, 2019 2:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Carrie Benchea   2721 Cabin Run Bridge Rd.  Thompson's Station, TN 37179   93 Jonathan Reeve From: Sent: To: Subject: kiddock@everyactioncustom.com on behalf of Tim Gillespie Thursday, October 17, 2019 2:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.”     As a pediatrician serving in the Memphis area, including Whitehaven, Hickory Hill, Bartlett, and Germantown, our group  sees the lifeline that TennCare provides.  These services are indispensible. We have been successful working with the  MCOs to provide top‐level care to the poorest in the state.   Cutting services, allowing non‐physicians to set limits that  will impair the health of children, and ultimately forcing independent physicians to align with hospitals is the path to  single‐payer model to which I, as a lifelong political conservative, am strongly opposed.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.    We HAVE to have what we as physicians need to take care of the children.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards.  Without such guardrails, the state could return to the  days when managed care contractors failed to provide care to patients and providers were left unpaid. This proposal  invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.     I respectfully urge you not to go forward with this harmful proposal.    Tim Gillespie, MD, FAAP  Memphis Children's Clinic      Sincerely,  Dr. Tim Gillespie  1129 Hale Rd  Memphis, TN 38116‐6373  kiddock@aol.com  94 Jonathan Reeve From: Sent: To: Subject: graypj826@everyactioncustom.com on behalf of Patrick Gray Thursday, October 17, 2019 3:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     I have heard too many stories of people harmed by mismanagement and poorly planned laws. This waiver is no  different.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patrick Gray  Nashville, TN 37209  graypj826@gmail.com  95 Jonathan Reeve From: Sent: To: Subject: gail.stover@everyactioncustom.com on behalf of Barbara Stover Thursday, October 17, 2019 2:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Barbara Stover  360 Sliger Rd  Cookeville, TN 38506‐5914 gail.stover@gmail.com  96 Jonathan Reeve From: Sent: To: Subject: Carolynfugate55@everyactioncustom.com on behalf of Carolyn Fugate Thursday, October 17, 2019 3:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the block grant. Here in Northeast Tennessee our health care system is in a shambles. Please don't make our children and seniors suffer any more.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Carolyn Fugate  6024 Roseberry Road Ext  Kingsport, TN 37660‐7935 Carolynfugate55@gmail.com  97 Jonathan Reeve From: Sent: To: Subject: Mary Hikes Thursday, October 17, 2019 3:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Mary Hikes   139 Chatuga Dr  Loudon, TN 37774   98 Jonathan Reeve From: Sent: To: Subject: kristiwells17@everyactioncustom.com on behalf of Kristi Wells Thursday, October 17, 2019 2:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    We have custody of three grandchild that depend on Tenncare for their health care needs we can not afford to lose  coverage as we are older and live on a fixed jncome to survive.  Please listen to the residents of Tennessee and do not pass this bill.    Please realize that so many people depend on Tenncare we should not have to choose between food or health care.  I don't know if we could even afford to keep our grandchildren if we lost their health insurance it wouldn't be fair to  them if we aren't able to provide them with the necessity of life.    Thank you for taking the time to review my comment.   Kristi Wells    Sincerely,  Mrs Kristi Wells  1425 Valley St  Kingsport, TN 37660‐4920 kristiwells17@gmail.com  99 Jonathan Reeve From: Sent: To: Subject: Charles McCullough Thursday, October 17, 2019 3:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant To whom it may concern:    I fully support the block grant proposal. Cost savings and fraud reduction are imperative in any government program.    Regards,    Charles McCullough  East Ridge, TN    Sent from ProtonMail Mobile  100 Jonathan Reeve From: Sent: To: Subject: toni.carrigan@everyactioncustom.com on behalf of Toni Carrigan Thursday, October 17, 2019 3:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Toni Carrigan  86 Dowlen Rd  Hixson, TN 37343‐2762  toni.carrigan@siskin.org  101 Jonathan Reeve From: Sent: To: Subject: sarahmasonclark@everyactioncustom.com on behalf of Sarah Clark Thursday, October 17, 2019 3:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. Many Tennesseans have been dropped from Medicaid in the past and there is  great uncertainty about how the state would manage the program with less government oversight.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sarah Clark  Nashville, TN 37215  sarahmasonclark@gmail.com  102 Jonathan Reeve From: Sent: To: Subject: nancyrogers3@everyactioncustom.com on behalf of Nancy Rogers Thursday, October 17, 2019 3:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Nancy Rogers  Chattanooga, TN 37415  nancyrogers3@yahoo.com  1 Jonathan Reeve From: Sent: To: Subject: janettortorelli@everyactioncustom.com on behalf of Janet Tortorelli Thursday, October 17, 2019 3:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Please do not implement block grants for Medicaid in Tennessee!  My adult daughter with Intellectual disabilities  depends on Medicaid for her only health insurance now that both her parents are retired. Her Bluecare Plus health  insurance is a lifeline.  In addition she is enrolled in the ECFC CHOICES waiver, which is the only help she’s had after  being on a waiting list most of her life.  It helps her to have a job, have transportation, and be involved in the  community. This is also funded through Medicaid.     Instead of using block grants, Tennessee should accept the expansion of Medicaid to cover many more of our citizens.  It’s a shame to leave that funding on the table and not help as many people as possible.  It’s only been a couple of years  that our daughter  has had these benefits. For the first time in her life, our state is really helping her. Block grants would  only encourage cutting benefits which are so greatly needed.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Janet Tortorelli  Knoxville, TN 37922  janettortorelli@gmail.com  2 Jonathan Reeve From: Sent: To: Subject: Kathleen Lewis Thursday, October 17, 2019 4:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Kathleen Lewis   305 Chuniloti Circle  Loudon, TN 37774   3 Jonathan Reeve From: Sent: To: Subject: patmcc911@everyactioncustom.com on behalf of Patricia McCauley Tuesday, October 15, 2019 4:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am writing to oppose giving Tennessee a Medicaid block grant.  As a citizen of Tennessee for almost 40 years, watching  and reading the news has shown me that the current state of our TennCare is really sad.  It was created in the 1990’s  and initially was great.  But years of mismanagement and lack of funding has left it in a mess. Tennessee is the last state I would trust with a blank check to do as it pleases with federal funding.  In the last few years, it has seen a 20% percent  increase in the number of uninsured children. Of the 100,000 children who lost coverage, TennCare does not know how  many children were actually ineligible and how many lost their coverage due to administrative issues.  TennCare had no  functioning computer system from 2014 to the recent present.    Our previous governor tried to get the state legislature to expand Medicaid and cover 300.000 more underinsured  Tennesseans.  The state legislature did not pass it.  Because of this lack of health insurance, 12 rural hospitals have  closed in Tennessee, leaving 21 counties without immediate access to an emergency room.  Giving Tennessee a block  grant for Medicaid will not stop these hospital closures.  In fact, it may increase them and start some nursing home  closures.    Listed in the block grant proposal, is an item to restrict patients to one medication only.  Obviously no medical personnel  were consulted in the writing of this proposal, as I cannot think of any serious illness that is treated with just one  medication.    This Block Grant proposal is purposely written to release Tennessee from federal oversight and accountability.  There is  even wording to the effect that if Tennessee is so efficient with its TennCare management, it can use state monies saved  for uses other than healthcare.    Please do not give Tennessee a Block Grant.  It is so busy counting pennies, it cannot see all the dollars it has wasted on  hospital closures and poor medical outcomes from lack of healthcare availability.      Sincerely,  Ms. Patricia McCauley  4511 Glendale Pl  Nashville, TN 37215‐3903 patmcc911@yahoo.com  4 Jonathan Reeve From: Sent: To: Subject: amy2410@everyactioncustom.com on behalf of Amy Foster Tuesday, October 15, 2019 4:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.      I am the conservator for a family member with severe mental health issues.  Our ability to place him in a Tenncare  Psychiatric home ended a severe cycle of homelessness, inpatient psychiatric hospitalizations, and criminal behavior,  where he was both a victim and a perpetrator.  There is no doubt in my mind that addressing his mental health needs  instead of ignoring them is a net cost benefit to the State of Tennessee.  This block grant proposal could end the  provision of intense care that he needs; the end result will not be a savings, but simply a transfer of expenses to other  sectors of the Tennessee economy ‐ increased police involvement, increased ambulance calls, an increase in treatment  in emergency rooms and the potential costs of incarceration, not to mention the unmeasurable cost of human misery.      Similarly, the possible limitations of providing early intervening services to children with disabilities and pregnant  women only increases the likelihood that those children will be less likely to become functioning adults; this is a penny‐ wise, pound‐foolish public policy proposal that should be rejected.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amy Foster  2600 White Moon Dr  Harker Heights, TX 76548‐2810 amy2410@yahoo.com  5 Jonathan Reeve From: Sent: To: Subject: ginnabetts@everyactioncustom.com on behalf of Virginia Trotter Betts Tuesday, October 15, 2019 4:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] The proposed Medicaid Block Grant is Harmful to Tennesseans!! PLEASE WITHDRAW!!   Dear Gabe Roberts,    I am writing this to OPPOSE your published proposal to alter Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize current and future coverage for vulnerable Tennesseans.  I am especially concerned about persons with  mental illnesses and substance use disorders....folks who need MORE not fewer services!!    Medicaid was created to assist children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority which it likely is unable to appropriately manage scientifically to select/cut services for these vulnerable  populations without normal federal oversight – and arbitrarily set inclusion criteria. The proposal opens Tennesseans to  no protections on which core health care services would be available such as mental health services, hospital services,  maternity care, etc. and  proposes to limit access to a range of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  This  proposal threatens the availability of vital health coverage for many Tennesseans and could damage health care services  for ALL in our state.     As a nurse and a health policy expert, I know that a block grant for Medicaid is NOT what Tennesseans need.  We need  Medicaid Expansion.  Spend your time on that, please.    Virginia Trotter Betts, RN, MSN, JD, FAAN        Sincerely,  Virginia Trotter Betts  Nashville, TN 37215  ginnabetts@aol.com  6 Jonathan Reeve From: Sent: To: Subject: wizardofoz789@everyactioncustom.com on behalf of Raven Goodwin Tuesday, October 15, 2019 5:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  Also coming from a single mother who has a  baby who has moderate hearing loss and needs hearing aids.     Sincerely,  Raven Goodwin  1161 Cora Ln Apt 2 Johnson City, TN 37615‐4738 wizardofoz789@yahoo.com  7 Jonathan Reeve From: Sent: To: Subject: mainland@everyactioncustom.com on behalf of Jean Mainland Tuesday, October 15, 2019 5:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I vehemently oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.  There are enough issues even under the current system; to give the state "carte  blanche" in oversight without the current federal regulations in place would be folly.    My sister is 55, and has Down Syndrome and dementia.  She lives with my sister and I, and we are her full time  caregivers.  We have been her caregivers for 30+ years after she was abandoned by the intellectual disabilities  department at age 21.  At some point in her future, it will become necessary for us to have more from the Medicaid  program.  As we age, we recognize that we may not be able to meet her needs without this assistance.  We want to be  sure she has them when the time comes    This waiver is fundamentally and tragically flawed and cannot be fixed. It goes against the goals and purpose of the  Medicaid program. We respectfully urge you not to go forward with this harmful proposal.  To issue this block grant  would be to the detriment of all Tennesseans who have intellectual and/or physical disabilities that need Medicaid to  survive.      Please stop this block grant.  Consider the wellbeing of ALL Tennesseans.    Sincerely,  Jean Mainland  113 Allen Dr  Hendersonville, TN 37075‐3827 mainland@peoplepc.com  8 Jonathan Reeve From: Sent: To: Subject: pcombs12@everyactioncustom.com on behalf of Patricia Combs Tuesday, October 15, 2019 5:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patricia Combs  502 Lullwater Rd  Chattanooga, TN 37405‐4618 pcombs12@epbfi.com  9 Jonathan Reeve From: Sent: To: Subject: hhagler48@everyactioncustom.com on behalf of Henrietta Hagler Tuesday, October 15, 2019 5:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Henrietta Hagler  Hendersonville, TN 37075  hhagler48@gmail.com  10 Jonathan Reeve From: Sent: To: Subject: volunteer@everyactioncustom.com on behalf of Jeanette Miller Tuesday, October 15, 2019 5:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal. Officious, Uncaring, Derelict Bureaucrats ... Keep your Filthy hands off of my moms' Medicaid! She is a handicapped, Dual-Eligible, Special Needs Widow surviving on SSA, VA Pension, and BlueCare+.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jeanette Miller  Village 520 Old Highway  Sweetwater, TN 37874 volunteer@reagan.com  11 Jonathan Reeve From: Sent: To: Subject: vgfloyd2@everyactioncustom.com on behalf of Vicki Floyd Tuesday, October 15, 2019 5:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Vicki Floyd  9639 Meadow Green Cv  Lakeland, TN 38002‐4283 vgfloyd2@gmail.com  12 Jonathan Reeve From: Sent: To: Subject: charitydugood@everyactioncustom.com on behalf of Jacqueline Sadlo Tuesday, October 15, 2019 5:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,    Jacqueline Sadlo    Sincerely,  Jacqueline Sadlo  1001 N Eastman Rd Unit 7578 Kingsport, TN 37664‐3176 charitydugood@gmail.com  13 Jonathan Reeve From: Sent: To: Subject: kmoser56@everyactioncustom.com on behalf of Kathy Zicher Tuesday, October 15, 2019 5:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Kathy Zicher  Hendersonville, TN 37075  kmoser56@hotmail.com  14 Jonathan Reeve From: Sent: To: Subject: kmoser56@everyactioncustom.com on behalf of Kathy Zicher Tuesday, October 15, 2019 5:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathy Zicher  Hendersonville, TN 37075  kmoser56@hotmail.com  15 Jonathan Reeve From: Sent: To: Subject: tdavis4248@everyactioncustom.com on behalf of Traci Davis Tuesday, October 15, 2019 6:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Why must the most vulnerable pay for this??    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Traci Davis  Mohawk, TN 37810  tdavis4248@gmail.com  16 Jonathan Reeve From: Sent: To: Subject: Kim Thornton Tuesday, October 15, 2019 6:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Kim Thornton   9231 Fox Run Dr  Brentwood, TN 37027   17 Jonathan Reeve From: Sent: To: Subject: mlgross0207@everyactioncustom.com on behalf of Michelle Gross Tuesday, October 15, 2019 6:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I offered public comment in person in Knoxville as well as stand by tgis message as well!   I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Michelle Gross  105 Jackson Ln  Jonesborough, TN 37659‐1511 mlgross0207@gmail.com  18 Jonathan Reeve From: Sent: To: Subject: krishana.s.donaldson@everyactioncustom.com on behalf of Krishana Overstreet Tuesday, October 15, 2019 6:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grants costs lives   Dear Gabe Roberts,    I am opposed to the proposal because it would cause immense harm and jeopardize coverage for vulnerable  Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Krishana Overstreet  207 Pennington Pl  Jackson, TN 38305‐3556 krishana.s.donaldson@vanderbilt.edu  19 Jonathan Reeve From: Sent: To: Subject: boudreauxfryar@everyactioncustom.com on behalf of Kelly Boudreaux Tuesday, October 15, 2019 6:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kelly Boudreaux  4123 Luther Rd  Bartlett, TN 38135‐1825  boudreauxfryar@gmail.com  20 Jonathan Reeve From: Sent: To: Subject: summermvazquez@everyactioncustom.com on behalf of Summer Vazquez Tuesday, October 15, 2019 6:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Oppose the block grant and lift the burden on the disabled of our community!   Dear Gabe Roberts,    This is Summer Vazquez. I live in Hamilton County, TN. I am writing to address some bills coming up in Congress this year  that deal with Supplemental Security Income (SSI). SSI has severe restrictions that make it difficult for disabled people to  achieve a decent quality of life. Lifting these restrictions is a nonpartisan human rights issue and would greatly benefit  those among us who are already limited by their own bodies to gain more independence and establish a better sense of  worth and value in society. It does not involve increasing the budget, simply raising the threshold for savings and income  limits, and protecting benefits for disabled people who wish to marry. If you want to know more about this program,  restrictions, and bills, please read the research done by Kale Sartor, which you can open here:    https://urldefense.com/v3/__https://docs.google.com/document/d/1l4mK3hz6RMpGesnfAlz6R‐ bwcutEPc7xcEJRB_p1z94/edit?usp=sharing__;!dyXff_z6q0o!_6jRbiZGUmvVtxAZdUxau58brVWyY5rWukRifxuiSAw9Body Wx3QFZ‐k5uqSx7ODHjm‐sGW9Gg$     Or you can correspond with her personally at:    akathleensartor@gmail.com    We’d like for this to be an ongoing conversation about access to resources for people with disabilities.     Thank you for your time and your service to Tennessee. I hope to hear from you soon.      Sincerely,  Summer Vazquez  Ooltewah, TN 37363  summermvazquez@gmail.com  21 Jonathan Reeve From: Sent: To: Subject: hubbard5159@everyactioncustom.com on behalf of Ashlie Hubbard Tuesday, October 15, 2019 7:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Stop the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ashlie Hubbard  Arlington, TN 38002  hubbard5159@bellsouth.net  22 Jonathan Reeve From: Sent: To: Subject: thurmanwalters94@everyactioncustom.com on behalf of Thurman Walters Tuesday, October 15, 2019 7:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr Thurman Walters  907 Antioch Rd  Johnson City, TN 37604‐7091 thurmanwalters94@gmail.com  23 Jonathan Reeve From: Sent: To: Subject: isenhour.judy@everyactioncustom.com on behalf of Judy Isenhour Tuesday, October 15, 2019 7:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Judy Isenhour  4500 Post Rd Unit B20 Nashville, TN 37205‐1512 isenhour.judy@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: bunnie.mcelyea@everyactioncustom.com on behalf of Chanda McElyea Tuesday, October 15, 2019 7:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Chanda McElyea  Church Hill, TN 37642  bunnie.mcelyea@gmail.com  25 Jonathan Reeve From: Sent: To: Subject: rachaelebarnett@everyactioncustom.com on behalf of Rachael Barnett Tuesday, October 15, 2019 7:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Rachael Barnett  Johnson City, TN 37604  rachaelebarnett@gmail.com  26 Jonathan Reeve From: Sent: To: Subject: georginiagibson@everyactioncustom.com on behalf of Georginia Gibson Tuesday, October 15, 2019 7:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Georginia Gibson  5301 Pleasant Hill Dr  Kingsport, TN 37664‐4616 georginiagibson@gmail.com  27 Jonathan Reeve From: Sent: To: Subject: lindseybaker18@everyactioncustom.com on behalf of Lindsey Baker Tuesday, October 15, 2019 7:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lindsey Baker  1413 1/2 Alhambra Dr  Lebanon, TN 37087‐8310 lindseybaker18@gmail.com  28 Jonathan Reeve From: Sent: To: Subject: ashley_mbrazle@everyactioncustom.com on behalf of Ashley Brazle Tuesday, October 15, 2019 7:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans like my daughter who was diagnosed with Williams Syndrome plus and requires  specialized care in every aspect of her life.       Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy (which our daughter needs and relies on Tenncare for services multiple times per week amongst other  therapies)– and arbitrarily limit who gets them. The proposal could also cut back on core health care services like  hospital care, without federal approval or public notice, and exclude coverage of the most effective prescription drugs  that are outside of our control as to whether or not our medically complex need and find them beneficial.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ashley Brazle  Baxter, TN 38544  ashley_mbrazle@yahoo.com  29 Jonathan Reeve From: Sent: To: Subject: koruss@everyactioncustom.com on behalf of Kathryn Russell Tuesday, October 15, 2019 7:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathryn Russell  1005 Stainback Ave  Nashville, TN 37207‐5719 koruss@bellsouth.net  30 Jonathan Reeve From: Sent: To: Subject: bw423@everyactioncustom.com on behalf of Brandi Wells Tuesday, October 15, 2019 7:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Brandi Wells  Johnson City, TN 37604  bw423@charter.net  31 Jonathan Reeve From: Sent: To: Subject: cg8684@everyactioncustom.com on behalf of Courtney Bedwell Tuesday, October 15, 2019 7:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Expanding Medicaid would be a great act of compassion. Please remember, when considering this merciless proposal for  block grants, some words from a far wiser counselor than me,”whatever you have done for the least of these, you have  also done for me.” ‐ Jesus Christ     Sincerely,  Courtney Bedwell  2790 Corinth Rd  Darden, TN 38328‐8653  cg8684@hotmail.com  32 Jonathan Reeve From: Sent: To: Subject: catfaber@everyactioncustom.com on behalf of Catherine Faber Tuesday, October 15, 2019 12:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Oppose Medicaid Block Grant Proposal!   Dear Gabe Roberts,    I volunteer at the Joining Hands Health Center and every shift I hear from people who are desperate for medical and  dental care‐‐and so much of the time I have to say no, because our resources are already insufficient to care for the  people Medicare isn't covering.  Block grants will just land more of these poor sufferers on our doorstep.  This is a  terrible idea.    Do not attempt to convert federal funding for TennCare into a block grant.     This idea is fundamentally flawed. It goes against the goals and purpose of the Medicaid program. I respectfully urge you  not to go forward with this harmful proposal.    Sincerely,  Catherine Faber  2002 Carolyn Dr  Jefferson City, TN 37760‐1508 catfaber@toast.net  33 Jonathan Reeve From: Sent: To: Subject: andrea.h.gannon@everyactioncustom.com on behalf of Andrea Gannon Tuesday, October 15, 2019 12:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Andrea Gannon  622 Georgia Ave  Chattanooga, TN 37402‐1406 andrea.h.gannon@gmail.com  34 Jonathan Reeve From: Sent: To: Subject: jross1038@everyactioncustom.com on behalf of James Ross Tuesday, October 15, 2019 12:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  James Ross  4916 Whittier Dr  Old Hickory, TN 37138‐1429 jross1038@aol.com  35 Jonathan Reeve From: Sent: To: Subject: t.sizemore@everyactioncustom.com on behalf of Casey Sizemore Tuesday, October 15, 2019 12:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Casey Sizemore  160 Hidden Lake Cv  Arlington, TN 38002‐8477 t.sizemore@comcast.net  36 Jonathan Reeve From: Sent: To: Subject: BTYMCC@everyactioncustom.com on behalf of Betty McConnell Tuesday, October 15, 2019 12:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] PLEASE PROTECT WORKING FAMILIES, CHILDREN AND THOSE WITH DISABILITIES FROM THIS HARMFUL BLOCK GRANT!!!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Betty McConnell  104 Surrey Hill Pt  Hendersonville, TN 37075‐5212 BTYMCC@aol.com  37 Jonathan Reeve From: Sent: To: Subject: bonnyb@everyactioncustom.com on behalf of Bonita Brockman Tuesday, October 15, 2019 12:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     In addition, this waiver would bring great harm to the elderly at a time in their lives when they are greatest in need of  healthcare.   Taking any Medicaid money currently designated for healthcare and allowing it to be redirected back to the federal or  state government budgets leaves too many opportunities for mismanagement or misuse of Medicaid funding designed  to care for Tennesseans.  The courts and legislators should work instead to protect those who are unable to speak or  protect themselves.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Bonita Brockman  235 Cullom Way  Clarksville, TN 37043‐6831 bonnyb@charter.net  38 Jonathan Reeve From: Sent: To: Subject: akh129@everyactioncustom.com on behalf of Anthea Hendrix Tuesday, October 15, 2019 12:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Anthea Hendrix  107 Flenniken Ave Apt 201 Knoxville, TN 37920‐2681 akh129@yahoo.com  39 Jonathan Reeve From: Sent: To: Subject: kbtn2010@everyactioncustom.com on behalf of James Brewer Tuesday, October 15, 2019 12:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  James Brewer  620 Truxton Dr  Nashville, TN 37214‐3411 kbtn2010@comcast.net  40 Jonathan Reeve From: Sent: To: Subject: maevans@everyactioncustom.com on behalf of Peggy Evans Tuesday, October 15, 2019 12:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal, as it is also very flawed and very mean spirited.    Sincerely,  Mrs. Peggy Evans  1615 Dellwood Ave  Cookeville, TN 38506‐4146 maevans@twlakes.net  41 Jonathan Reeve From: Sent: To: Subject: kbtn1573@everyactioncustom.com on behalf of Holly Smith Tuesday, October 15, 2019 12:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Holly Smith  620 Truxton Dr  Nashville, TN 37214‐3411 kbtn1573@gmail.com  42 Jonathan Reeve From: Sent: To: Subject: jimikelley@everyactioncustom.com on behalf of James Kelley Tuesday, October 15, 2019 12:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Stop the Block Grant   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     As a grandfather with 2 children dependent on Tenn‐Care for daily maintenance of a life‐threatening medical condition,  these continued predatory cuts to Tenn‐Care are aimed at increasing revenue for MCOs at the expensive of our citizens.   Medicaid is intended to help those in need as is our duty to God and to our fellow human beings.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    James W. Kelley III    Sincerely,  James Kelley  810 Bellevue Rd  Nashville, TN 37221‐2729 jimikelley@yahoo.com  43 Jonathan Reeve From: Sent: To: Subject: stacynunnally@everyactioncustom.com on behalf of Stacy Nunnally Tuesday, October 15, 2019 12:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Stacy Nunnally  4321 Huntwood Dr  Murfreesboro, TN 37129‐0312 stacynunnally@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: jonnaz@everyactioncustom.com on behalf of Jon Nasrallah Tuesday, October 15, 2019 12:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable friends and neighbors.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     If anything, TennCare needs more accountability, not less. The state should not be allowed to make changes to the  Medicaid program without federal oversight or eliminate federal standards, which are in place for the protection of  patients. Without such guardrails, the state could return to the days when managed care contractors failed to provide  care to patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of  vital health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jon Nasrallah  Nashville, TN 37216  jonnaz@comcast.net  45 Jonathan Reeve From: Sent: To: Subject: elizabeth.h.manning@everyactioncustom.com on behalf of Elizabeth Manning Tuesday, October 15, 2019 1:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. As a biomedical sciences worker, I often interact  with people who would be unable to access life‐saving medical treatments if their insurance was suddenly lost, and their  lives are valuable to me. On behalf of them, I stand firmly opposed to the Medicaid block grant.    Sincerely,  Elizabeth Manning  522 Bellmore Pl  Nashville, TN 37209‐3173 elizabeth.h.manning@gmail.com  46 Jonathan Reeve From: Sent: To: Subject: mjcomptn@everyactioncustom.com on behalf of Michael Compton Tuesday, October 15, 2019 1:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Michael Compton  5021 Coro Rd  Memphis, TN 38109‐6124  mjcomptn@gmail.com  47 Jonathan Reeve From: Sent: To: Subject: carlabolles@everyactioncustom.com on behalf of Carla Bolles Tuesday, October 15, 2019 1:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Carla Bolles  1012 Gale Ln  Nashville, TN 37204‐2914  carlabolles@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: cassandra.anello@everyactioncustom.com on behalf of Cassandra Anello Tuesday, October 15, 2019 1:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Cassandra Anello  555 Church St  Nashville, TN 37219‐2352  cassandra.anello@davidsondemocrats.org  49 Jonathan Reeve From: Sent: To: Subject: colin.pigott@everyactioncustom.com on behalf of Colin Pigott Tuesday, October 15, 2019 1:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     The Affordable Care Act already provides amazing opportunities and incentives for expanding Medicaid in Tennessee;  we should seek to walk that path instead.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Colin Pigott  Nashville, TN 37209  colin.pigott@gmail.com  50 Jonathan Reeve From: Sent: To: Subject: Rebecca Jones Tuesday, October 15, 2019 1:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Rebecca Jones   111 Cloverfield Ct  Hendersonville, TN 37075   51 Jonathan Reeve From: Sent: To: Subject: emily.green-cain@everyactioncustom.com on behalf of Emily Green Cain Tuesday, October 15, 2019 1:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Emily Green Cain  2327 Riverstone Dr  Murfreesboro, TN 37128‐6726 emily.green‐cain@comcast.net  52 Jonathan Reeve From: Sent: To: Subject: kitten.173060@everyactioncustom.com on behalf of Sonya Weber Tuesday, October 15, 2019 1:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sonya Weber  905 Dutch Valley Dr  Knoxville, TN 37918‐1421 kitten.173060@yahoo.com  53 Jonathan Reeve From: Sent: To: Subject: ellenfinney60@everyactioncustom.com on behalf of Ellen Finney Tuesday, October 15, 2019 1:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Ellen Finney  199 Broadwell Cir  Franklin, TN 37067‐1624 ellenfinney60@gmail.com  54 Jonathan Reeve From: Sent: To: Subject: shesapill@everyactioncustom.com on behalf of Diane Paradise Tuesday, October 15, 2019 2:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As the parent of a child with multiple disabilities, I am very concerned over what this proposal would mean to our most  vulnerable residents of Tennessee. I am opposed to the proposal to radically change Tennessee’s Medicaid partnership  with the federal government by converting federal funding for TennCare into a “block grant.”     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need.   TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards.     Sincerely,  Diane Paradise  901‐219‐9265    Sincerely,  Diane Paradise  8463 Rothchild Rd  Germantown, TN 38139‐3300 shesapill@aol.com  55 Jonathan Reeve From: Sent: To: Subject: thelatestword@everyactioncustom.com on behalf of Angela Gibson Tuesday, October 15, 2019 2:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] NO to turning TNCare into "Block Grant"   Dear Gabe Roberts,    My mom is paraplegic in a wheelchair and relies on the Choices program. Keeping our citizens OUT of nursing homes as  long as possible IS CRITICAL.  Won't you help toward doing that?  It is also important to RELAX restrictions so that my mom is able to choose an assisted living facility INSTEAD of a nursing  home where her mental and physical health would surely decline.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Angela Gibson  8615 Boone Hall Ct  Knoxville, TN 37923‐6355 thelatestword@aol.com  56 Jonathan Reeve From: Sent: To: Subject: mbick7@everyactioncustom.com on behalf of Margaret Bickley Tuesday, October 15, 2019 2:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    As an RN who has worked since 1986 at East TN Children's Hospital, I have seen our patients and families adversely  affected by having health coverage in jeopardy. All first world nations provide health care to those who need it; these  United States, including my home state of Tennessee, should do the same. Please defeat this proposal.     Thank you for your time and attention to this important issue.     Sincerely,  Margaret Bickley  5408 Pinecrest Rd  Knoxville, TN 37912‐2933 mbick7@gmail.com  57 Jonathan Reeve From: Sent: To: Subject: icecube5977@everyactioncustom.com on behalf of Kacey Carson Tuesday, October 15, 2019 2:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    My family, my children and myself, rely on tenncare and the blatant disregard for people and their health is appalling  and the most inconsiderate thing about this.     Sincerely,  Kacey Carson  Chattanooga, TN 37411  icecube5977@yahoo.com  58 Jonathan Reeve From: Sent: To: Subject: kspry@everyactioncustom.com on behalf of Kathryn Spry Tuesday, October 15, 2019 2:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathryn Spry  2414 Spaulding Cir  Murfreesboro, TN 37128‐4823 kspry@comcast.net  59 Jonathan Reeve From: Sent: To: Subject: akathleensartor@everyactioncustom.com on behalf of Kale Sartor Tuesday, October 15, 2019 2:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] PLEASE do not pass the Medicaid Block Proposal!   Dear Gabe Roberts,    I am a disabled individual who worked hard and sacrificed a lot to finally get on the SSI program and receive Medicaid. I  need frequent treatments that I would not be able to afford out of pocket, and sometimes I require expensive testing.  Without Medicaid coverage, I will not be able to get the care I need. Many others like me, disabled, elderly, and children  are the weakest among the population. Medicaid block grants would strip away the already very limited protections we  have and lead to lower quality of life, serious drops in health, and perhaps even death.    It is hard for people in these most disadvantaged groups to get out and protest, to attend meetings, to find out about  these proposals and send out comments on them. It is unjust and unfair to take away our healthcare.     We should be expanding Medicaid to cover more vulnerable people, not reforming it to cover less.      I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kale Sartor  3804 Mission View Ave Apt 2 Chattanooga, TN 37411‐5131 akathleensartor@gmail.com  60 Jonathan Reeve From: Sent: To: Subject: lmnelson08@everyactioncustom.com on behalf of Lisa Orucevic Tuesday, October 15, 2019 2:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.  I know the importance of TennCare firsthand because my family was on public  assistance, and I essentially grew up on TennCare.  TennCare was the only reason that I as a child was able to see a  doctor or get medical help.  With help like that, I was able to grow up and become successful ‐ I had a successful career  for eleven years, and I am now in law school.  Further, my father is on disability and is in poor physical and mental  health, and he relies on TennCare every day to get the help he needs.  Even with TennCare and disability, I have to help  my dad just so he can get by.  This proposal could kick sick people like my father off of TennCare, and then the care and  expense falls to people like me.  Having to provide full time care to my dad would take me out of the work force where I  am earning money and paying taxes.  My story is far from unique ‐ pushing the care of the elderly and disabled onto  family and friends HARMS OUR ECONOMY by taking viable workers out of the workforce.  Another example I can give is  my sister who has extreme learning disabilities. While she has a job and healthcare through her factory job now, if the  factory closes, she may not be able to get another job and would need TennCare.  With a block grant, people like my  sister would definitely be excluded from TennCare even though she needs extra help.  This proposal threatens the future  of so many people in this state.       Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lisa Orucevic  Nashville, TN 37215  lmnelson08@gmail.com  61 Jonathan Reeve From: Sent: To: Subject: emily.m.slifkin@everyactioncustom.com on behalf of Emily Slifkin Tuesday, October 15, 2019 2:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I had my first legal internship this summer at TennCare, and realized all of the good work that the employees of  TennCare would like to pursue, but would be limited by the block grant. The block grant is clearly the state's message to  poor and underprivileged people that their healthcare does not matter. Perhaps instead of a block grant to save money,  the state could wage more taxes by perhaps having a more equitable income tax program, instead of the regressive  sales tax program.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Emily Slifkin  1600 Mcgavock St  Nashville, TN 37203‐3596 emily.m.slifkin@vanderbilt.edu  62 Jonathan Reeve From: Sent: To: Subject: rjenn2964@everyactioncustom.com on behalf of Richard Jennings Tuesday, October 15, 2019 2:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Richard Jennings  Cleveland, TN 37312  rjenn2964@yahoo.com  63 Jonathan Reeve From: Sent: To: Subject: dianern1963@everyactioncustom.com on behalf of Diane Brown Tuesday, October 15, 2019 2:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Diane Brown  2410 Spaulding Cir  Murfreesboro, TN 37128‐4823 dianern1963@bellsouth.bet  64 Jonathan Reeve From: Sent: To: Subject: alanwheeler1@everyactioncustom.com on behalf of Alan Wheeler Tuesday, October 15, 2019 3:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Alan Wheeler  Cleveland, TN 37323  alanwheeler1@gmail.com  65 Jonathan Reeve From: Sent: To: Subject: emily.passino@everyactioncustom.com on behalf of Emily Passino Tuesday, October 15, 2019 3:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” My major concern is based on a fundamental admiration of  how TennCare staff have sought ways to lower operating costs over the past several years. While there may still be  some fat to cut, the primary way for the block grant to achieve significant savings has to come from medical services  offered to enrollees‐ which would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposald invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Emily Passino  Nashville, TN 37212  emily.passino@gmail.com  66 Jonathan Reeve From: Sent: To: Subject: rachaelledbetter@everyactioncustom.com on behalf of Rachael Ledbetter Tuesday, October 15, 2019 3:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing the Medicaid Block Grant Proposal   Dear Gabe Roberts,    My name is Rachael Ledbetter, and I am a third‐year law student at the University of Memphis School of Law.  As a  student attorney in the Medical‐Legal Partnership Clinic, access to quality healthcare is particularly important to me.    I am fundamentally and ethically opposed to the proposal to convert TennCare into a block grant. The consequences of  this destructive proposal will lead to an increased number of Tennesseans without coverage and without access to  healthcare. Under the block grant proposal, the state will not have sufficient funds to provide healthcare coverage for  people who need it. In addition, the state is proposing to have the ability to change eligibility requirements. The  proposal is a direct yet surreptitious attack on vulnerable Tennesseans and their families.     My mother is a physician, and I grew up making rounds with her and watching her care for her patients in our rural,  Tennessee town. Many Tennesseans do not have adequate access to healthcare and insurance as it is, and I have seen  firsthand how lack of healthcare coverage can affect Tennesseans and their families. My mother taught me the  importance of defending people who are vulnerable, and this proposal will lead to even more citizens of our state  without coverage for their basic healthcare needs.     This is clear: People will die if this proposal goes into effect, and the ones who will suffer the most are our poorest,  oldest, and most vulnerable neighbors. Rather than legitimize this impractical, ineffective, and harmful proposal, our  civic leaders should join the 36 other states who have expanded Medicaid and allow better access to healthcare for all  Tennesseans.     I am opposed to the block grant proposal, because it gives the state the authority to cut services and eliminate  Tennesseans’ health coverage as they please without any accountability. TennCare coverage is vital for my clients in the  MLP Clinic at the Law School. We currently have a client who is a child and ventilator dependent, and if her services are  cut, it will be fatal. Supporters of this proposal argue it will help save the state money, but the real cost of these financial  savings will be the many human lives lost as a consequence and will forever outweigh any imagined financial benefit of  this proposal.     I respectfully but vehemently urge you not to proceed with this harmful and unjust proposal. If you value the lives of  Tennesseans and their access to healthcare, then expand Medicaid in our state instead. Thank you.    Sincerely,  Rachael Ledbetter  1112 Island Pl E  Memphis, TN 38103‐8898 rachaelledbetter@gmail.com  67 Jonathan Reeve From: Sent: To: Subject: kevin.b.witenoff@everyactioncustom.com on behalf of Kevin Witenoff Tuesday, October 15, 2019 3:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kevin Witenoff  Nashville, TN 37201  kevin.b.witenoff@vanderbilt.edu  68 Jonathan Reeve From: Sent: To: Subject: cath.hood@everyactioncustom.com on behalf of Catherine Hood Tuesday, October 15, 2019 3:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] NO to Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I am fortunate enough to have health insurance from my employer, but I work with students who rely on TennCare.  So  many families are dropped from TennCare suddenly and without notice, families with children who need coverage.  TennCare needs MORE accountability, not less. The state should not be allowed to eliminate federal standards. I know  that federal programs aren't perfect, but those guardrails are still important, and we should work to improve the  guardrails instead of destroying them.  We need to eliminate fraud and keep our children (and other vulnerable people)  safe.    I respectfully urge you NOT to adopt this harmful proposal.    Sincerely,  Catherine Hood  Murfreesboro, TN 37130  cath.hood@gmail.com  69 Jonathan Reeve From: Sent: To: Subject: hannah.l.masters@everyactioncustom.com on behalf of Hannah Masters Tuesday, October 15, 2019 4:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Hannah Masters  715 Cleo Miller Dr  Nashville, TN 37206‐2591 hannah.l.masters@vanderbilt.edu  70 Jonathan Reeve From: Sent: To: Subject: sarriah.anita@everyactioncustom.com on behalf of Sarriah Gibson Monday, October 21, 2019 10:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Giving aid to "indigents" will benefit society as a whole. Providing healthcare will enable those who have less to become  more independent. Cutting off resources prior to their getting established is not beneficial and will lead to their failure  and to our failure as a society.     Sincerely,  Sarriah Gibson  7132 Mimosa Trl  Milan, TN 38358‐6823  sarriah.anita@gmail.com  71 Jonathan Reeve From: Sent: To: Subject: dexxibugg@everyactioncustom.com on behalf of Desiree Conatser Thursday, October 17, 2019 6:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Desiree Conatser  Cookeville, TN 38501  dexxibugg@gmail.com  72 Jonathan Reeve From: Sent: To: Subject: vanaya@everyactioncustom.com on behalf of Veronica Anaya Thursday, October 17, 2019 7:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Veronica Anaya  Suncook, NH 03275  vanaya@gmail.com  73 Jonathan Reeve From: Sent: To: Subject: craigiemarianne43@everyactioncustom.com on behalf of Marianne Craigie Thursday, October 17, 2019 7:10 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marianne Craigie  1005 Lawson Rd  Crossville, TN 38571‐0537 craigiemarianne43@gmail.com  74 Jonathan Reeve From: Sent: To: Subject: michelleposs@everyactioncustom.com on behalf of Alissa Poss Thursday, October 17, 2019 7:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Alissa Poss  301 Demonbreun St  Nashville, TN 37201‐2232 michelleposs@spmlawfirm.com  75 Jonathan Reeve From: Sent: To: Subject: oldplugs@everyactioncustom.com on behalf of Dennis Mullins Thursday, October 17, 2019 7:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I am a disabled veteran and I am concerned about other disabled veterans who may not have access to VA benefits or  insurance.   TennCare being taken away from them would be detrimental.   My 91 year old Mother‐in‐law depends on  the QMB (Medicaid) to assist in her medical care and should she need nursing home care, it would be essential.  Other  family members are depending on this assistance for their children’s healthcare.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dennis Mullins  Kingsport, TN 37665  oldplugs@chartertn.net  76 Jonathan Reeve From: Sent: To: Subject: ccoop2392@everyactioncustom.com on behalf of Casey Cooper Thursday, October 17, 2019 8:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Casey Cooper  Chattanooga, TN 37421  ccoop2392@gmail.com  77 Jonathan Reeve From: Sent: To: Subject: katqualls68@everyactioncustom.com on behalf of Katherine Qualls Thursday, October 17, 2019 8:13 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.  We have a special needs grandchild and feel this block will jeopardize healthcare  for him as well as many others! We say no to this ! It will hurt many children!     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Katherine Qualls  Mount Carmel, TN 37645  katqualls68@gmail.com  78 Jonathan Reeve From: Sent: To: Subject: feltgoodfibers@everyactioncustom.com on behalf of Breanna Kincaid Thursday, October 17, 2019 8:18 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Oppose Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Breanna Kincaid  6944 Tom Lafever Rd  Silver Point, TN 38582‐6421 feltgoodfibers@yahoo.com  79 Jonathan Reeve From: Sent: To: Subject: southerngrl_77@everyactioncustom.com on behalf of Lesia Thomas Thursday, October 17, 2019 8:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I have COPD.  I require a ventilator.  If my Tenncare were to be cut, I would die.      Sincerely,  Mrs. Lesia Thomas  1994 King Springs Rd  Johnson City, TN 37601‐7002 southerngrl_77@yahoo.com  80 Jonathan Reeve From: Sent: To: Subject: aprendero@everyactioncustom.com on behalf of Joe Thomas Thursday, October 17, 2019 8:36 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I was disenrolled when Governor Bredesen "fixed" Tenncare.  I am very afraid that if this Block Grant goes through, my  wife would either completely lose, or have her coverage reduced.  She has COPD, and requires a ventilator.  She would  die if her coverage is reduced or stopped.     Tennessee should just take the federal funds that are available for expanding Medicaid.  The money is there.  It is a n  injustice to all Tennesseans to refuse these funds in favor of this half‐baked Block Grant.      Sincerely,  Mr. Joe Thomas  1994 King Springs Rd  Johnson City, TN 37601‐7002 aprendero@hotmail.com  81 Jonathan Reeve From: Sent: To: Subject: ltiscia07@everyactioncustom.com on behalf of Leslie Tiscia Thursday, October 17, 2019 8:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Leslie Tiscia  Memphis, TN 38114  ltiscia07@gmail.com  82 Jonathan Reeve From: Sent: To: Subject: msmullins77@everyactioncustom.com on behalf of Marsha Mullins Thursday, October 17, 2019 9:13 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     As the wife of a disabled veteran and the daughter of a 91 year old mother, I am deeply opposed to this “block grant”!    Should my mother, myself, or other family members require nursing home care, the insurance we have now may not  cover the costs.  Veterans who do not currently have insurance coverage may not be able to get services they need.  I  also have a niece, a single mother of three children, who is working at a steady job but the insurance she has does not  cover all her children’s medical needs.   My mother’s social security check does not cover all her medical needs either  and she depends on her QMB (Medicaid) to assist in medical coverage.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marsha Mullins  Kingsport, TN 37665  msmullins77@hotmial.com  83 Jonathan Reeve From: Sent: To: Subject: Meghan Beasy Thursday, October 17, 2019 9:35 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Meghan Beasy   8375 Westfair Cir. N  Germantown, TN 38139   84 Jonathan Reeve From: Sent: To: Subject: Margaret Burd Thursday, October 17, 2019 9:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Margaret Burd   3819 West End Ave. #7  Nashville, TN 37205   85 Jonathan Reeve From: Sent: To: Subject: bahlinger61@everyactioncustom.com on behalf of Cliff Bahlinger Thursday, October 17, 2019 10:05 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Save TN care   Dear Gabe Roberts,    We in TN need an expansion of TN care and Medicare. I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Cliff Bahlinger  2067 Shetland Cv  Cordova, TN 38016‐5194 bahlinger61@gmail.com  86 Jonathan Reeve From: Sent: To: Subject: nankrichinsky@everyactioncustom.com on behalf of Anna Krichinsky Thursday, October 17, 2019 9:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, like my 41 year‐old disabled son, Seth.     Because of the services Seth has received over the years though the medicaid programs, he has been able to work part  time at UTMC, to live in a supported environment, and to be a participant in the working force, which benefits the state  of Tennessee.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Anna Krichinsky  Knoxville, TN 37909  nankrichinsky@gmail.com  87 Jonathan Reeve From: Sent: To: Subject: j317c@everyactioncustom.com on behalf of Janice Cowan Thursday, October 17, 2019 10:18 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Janice Cowan  196 Anco Dr  Kingsport, TN 37664‐5209  j317c@aol.com  88 Jonathan Reeve From: Sent: To: Subject: seajane@everyactioncustom.com on behalf of jane johnson Thursday, October 17, 2019 10:36 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.   Our hospital is closed in Fentress County and recently a 7 year old child died in an  ambulance trying to get to a hospital for care.  You are killing us.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  jane johnson  2665 Roslin Rd  Deer Lodge, TN 37726‐5007 seajane@yahoo.com  89 Jonathan Reeve From: Sent: To: Subject: Gregory Paule Thursday, October 17, 2019 10:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Gregory Paule   8966 Morning Grove Cove  , TN 38018   90 Jonathan Reeve From: Sent: To: Subject: Deborah Reeves Thursday, October 17, 2019 10:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Deborah Reeves   6764 Amersham Dr  Memphis, TN 38119   91 Jonathan Reeve From: Sent: To: Subject: rsc_smith@everyactioncustom.com on behalf of Susan Smith Thursday, October 17, 2019 10:49 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Susan Smith  Rogersville, TN 37857  rsc_smith@yahoo.com  92 Jonathan Reeve From: Sent: To: Subject: blangley218@everyactioncustom.com on behalf of Barbara Whitset Thursday, October 17, 2019 10:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Keep Tenncare   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Barbara Whitset  1043 Merrick Rd  Hendersonville, TN 37075‐1722 blangley218@gmail.com  93 Jonathan Reeve From: Sent: To: Subject: flexibleyogini@everyactioncustom.com on behalf of Db Reisen Thursday, October 17, 2019 10:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Db Reisen  Chattanooga, TN 37421  flexibleyogini@gmail.com  94 Jonathan Reeve From: Sent: To: Subject: sheilahgravely@everyactioncustom.com on behalf of Sheila Hopkins Gravely Thursday, October 17, 2019 10:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. I worked as a medical social worker for years and I fear that the block grant will  limit services to our sick elderly and those with marginal resources who need health care      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sheila Hopkins Gravely  1029 Forest Harbor Dr  Hendersonville, TN 37075‐9650 sheilahgravely@att.net  95 Jonathan Reeve From: Sent: To: Subject: linhartj@everyactioncustom.com on behalf of Rosemarie Linhart Thursday, October 17, 2019 10:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rosemarie Linhart  41 Calderwood Cir  Crossville, TN 38558‐7445 linhartj@sbcglobal.net  96 Jonathan Reeve From: Sent: To: Subject: Yasi Phillips Thursday, October 17, 2019 11:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Yasi Phillips   1035 Willow Trail  Goodlettsville, TN 37072   97 Jonathan Reeve From: Sent: To: Subject: Martin Quinton Thursday, October 17, 2019 11:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Martin Quinton   6478 Croft Oaks Cv  Bartlett, TN 38134   98 Jonathan Reeve From: Sent: To: Subject: clparker@everyactioncustom.com on behalf of Cynthia Parker Thursday, October 17, 2019 11:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans like my autistic son.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Cynthia Parker  6621 Declaration Dr  Hixson, TN 37343‐3458 clparker@epbfi.com  99 Jonathan Reeve From: Sent: To: Subject: lb.sanderson@everyactioncustom.com on behalf of Leslie Sanderson Thursday, October 17, 2019 11:20 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Leslie Sanderson  Cookeville, TN 38506  lb.sanderson@gmail.com  100 Jonathan Reeve From: Sent: To: Subject: myrayj@everyactioncustom.com on behalf of Myra Miller Thursday, October 17, 2019 11:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Myra Miller  Smithville, TN 37166  myrayj@hotmail.com  1 Jonathan Reeve From: Sent: To: Subject: dhat67@everyactioncustom.com on behalf of Dennis Hatler Thursday, October 17, 2019 11:23 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Dennis Hatler  761 Hatler Rd  Crossville, TN 38555‐0029 dhat67@frontier.com  2 Jonathan Reeve From: Sent: To: Subject: marjorie4statehousedist11@everyactioncustom.com on behalf of Marjorie Ramsey Thursday, October 17, 2019 11:24 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for Tenn Care into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Tenn  Care needs more accountability, not less. The state should not be allowed to make changes to the Medicaid program  without federal oversight or eliminate federal standards, which are in place for the protection of patients. Without such  guardrails, the state could return to the days when managed care contractors failed to provide care to patients and  providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital health coverage  for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marjorie Ramsey  2295 Highway 160  Newport, TN 37821‐4666 marjorie4statehousedist11@gmail.com  3 Jonathan Reeve From: Sent: To: Subject: mrsdiamond3@everyactioncustom.com on behalf of Civil Miller-Watkins Thursday, October 17, 2019 11:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Civil Miller‐Watkins  Rossville, TN 38066  mrsdiamond3@gmail.com  4 Jonathan Reeve From: Sent: To: Subject: msdgaf.marshall62@everyactioncustom.com on behalf of Chelsea Tristan Thursday, October 17, 2019 11:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Chelsea Tristan  Jacksonville, NC 28546  msdgaf.marshall62@gmail.com  5 Jonathan Reeve From: Sent: To: Subject: marjorie4statehousedist11@everyactioncustom.com on behalf of Marjorie Ramsey Thursday, October 17, 2019 11:20 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marjorie Ramsey  2295 Highway 160  Newport, TN 37821‐4666 marjorie4statehousedist11@gmail.com  6 Jonathan Reeve From: Sent: To: Subject: Nick Gant Thursday, October 17, 2019 11:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    My son has cystic fibrosis (CF). I am writing to express my serious concerns with Tennessee’s 1115 Demonstration  Waiver. The state’s request to change TennCare’s benefits structure without federal oversight, implement a closed  formulary, and waive additional federal Medicaid requirements – coupled with the proposed block grant financing  structure – could lead to limited eligibility, decreased access to care, and reduced benefits for people with CF who rely  on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Nick Gant   1180 Lakewood Cove  Collierville, TN 38017   7 Jonathan Reeve From: Sent: To: Subject: dhicks_1@everyactioncustom.com on behalf of Donna Hicks Thursday, October 17, 2019 11:36 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. Why would anyone want to harm the most vulnerable amongst us?    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs. This goes against the goal of creating a more healthy  population. Denying care will only exasperate the situation.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans. This will also increase health care costs to the rest of the population.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program. We respectfully urge you not to go forward with this harmful proposal. Tennesseans do not want to be a failed  experiment in health care delivery. Please reconsider Medicaid Expansion instead of this dangerour block grant.     Sincerely,  Donna Hicks  103 County Road 572  Englewood, TN 37329‐5110 dhicks_1@comcast.net  8 Jonathan Reeve From: Sent: To: Subject: kimdemetrio@everyactioncustom.com on behalf of Kim Demetrio Thursday, October 17, 2019 11:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kim Demetrio  1013 N 16th St  Nashville, TN 37206‐2505 kimdemetrio@gmail.com  9 Jonathan Reeve From: Sent: To: Subject: kimcounterman8@everyactioncustom.com on behalf of Kimberly Counterman Thursday, October 17, 2019 11:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kimberly Counterman  Athens, TN 37303  kimcounterman8@gmail.com  10 Jonathan Reeve From: Sent: To: Subject: demetreon1981@everyactioncustom.com on behalf of Alice Demetreon Thursday, October 17, 2019 11:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Healthcare in TN is already dismal as compared to other states. I do not trust the state legislature to protect the  healthcare rights of its' citizens. When the legislature uses the same insurance AND PAYS the same premiums as the rest  of us, then I might believe they would keep healthcare affordable. Until then, NO to Block Grant. I will be watching how  everyone votes and cast my ballot accordingly at the next election.     Sincerely,  Alice Demetreon  550 Colony Rd  Coalmont, TN 37313‐7901  demetreon1981@gmail.com  11 Jonathan Reeve From: Sent: To: Subject: jaglass37@everyactioncustom.com on behalf of James Glass Thursday, October 17, 2019 11:49 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss James Glass  3658 N Trezevant St  Memphis, TN 38127‐4650 jaglass37@yahoo.com  12 Jonathan Reeve From: Sent: To: Subject: csquared2911@everyactioncustom.com on behalf of Courtney Johnson Thursday, October 17, 2019 11:49 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am one of many people who are on TennCare. I have autism, multiple traumatic brain injuries, dysautonomia, a mild  neurocognitive disorder, am hard of hearing, and have several other medical conditions that significantly impact my  every day life. I am a wheelchair user and also often use a communication device to communicate when I get  overwhelmed.  I am also in the ECF Choices program because I am unable to live alone safely due to the autism and  other conditions.     I have to see many doctors ‐ including cardiology, neurology, different specialists at Vanderbilt, an infusion center, a  physical therapist, an occupational therapist, and a lot more.     My health is not very good and my body does not work right. It doesn’t control things properly, like my heart rate, blood  pressure, body temperature, breathing, digestion, and more things. This means that I have to go to the doctor and  sometimes the hospital a lot, because there are a lot of things that go wrong. I have episodes where I faint, have  seizures, and stroke‐like events that they think might be mini‐strokes. I also catch illnesses a lot, like when I had MRSA  last year.    Without Tenncare, I would not be alive right now. I know it sounds dramatic, but it is just simply true. I am on a lot of  medications that I need to function. TennCare has allowed me to have my medical things covered and supported, so I  can focus on  doing things like go to college and volunteer to help other people.       Not only that, but any “outside” health insurance would not cover my home care ‐ which I need in order to stay out of  an institution, and live independently and safely.    I do not want a block grant, because this could impact the healthcare of thousands of people who need TennCare to  survive.    My little brother is also autistic like me and is on Medicaid. He is a ward of the court and being raised by my  grandparents, like I once was. They live in middle Tennessee, and TennCare is very important for my brother too. He has  been in a lot of therapies and sees different doctors.    We both need TennCare to not be destabilized into a block grant. We want to live, work, and experience life just like  anyone else ‐ and we need healthcare in order to do that.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  13 therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Courtney Johnson  2214 S Greenwood Dr Apt 8 Johnson City, TN 37604‐7023 csquared2911@gmail.com  14 Jonathan Reeve From: Sent: To: Subject: szchamberspowell@everyactioncustom.com on behalf of Sarah Powell Thursday, October 17, 2019 11:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    My husband and I both work full time jobs and always have, But private insurance is still unattainable for our family. The  two of us are uninsured, but thanks to programs like Tenncare and Coverkids, my children have received invaluable care.  I also work in the public school system, and so many of our students rely on these services. Of they were not to have  access it could mean life or death to many of them.     Please do not allow State of Tennessee legislators to further jeopardize our care as they did by refusing the Medicare  expansion.     Healthcare should be a right to us all, and the most vulnerable of us deserve to be heard and cared for regardless of our  socioeconomic status.    Sincerely,  Sarah Chambers‐Powell    Sincerely,  Mrs Sarah Powell  1074 Baker Ave  Knoxville, TN 37920‐2506 szchamberspowell@gmail.com  15 Jonathan Reeve From: Sent: To: Subject: Jordan Beard Wednesday, October 16, 2019 8:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Jordan Beard   104 Blade Ct  Murfreesboro, TN 37127   16 Jonathan Reeve From: Sent: To: Subject: trish_willette@everyactioncustom.com on behalf of Trish Willette Wednesday, October 16, 2019 8:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Trish Willette  1923 Honaker Ct  Johnson City, TN 37615‐2792 trish_willette@yahoo.com  17 Jonathan Reeve From: Sent: To: Subject: kristan.buckner499@everyactioncustom.com on behalf of Kristan Buckner Wednesday, October 16, 2019 8:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kristan Buckner  220 Eller Dr  Dixon Springs, TN 37057‐5053 kristan.buckner499@topper.wku.edu  18 Jonathan Reeve From: Sent: To: Subject: kordikheather@everyactioncustom.com on behalf of Heather Patterson Wednesday, October 16, 2019 8:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Heather Patterson  401 Sunbny Ridfe Cir  Dickson, TN 37055  kordikheather@gmail.com  19 Jonathan Reeve From: Sent: To: Subject: Tenn819@everyactioncustom.com on behalf of Mariah Benimon Wednesday, October 16, 2019 8:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mariah Benimon  Goodlettsville, TN 37072  Tenn819@aol.com  20 Jonathan Reeve From: Sent: To: Subject: alyxandradavis@everyactioncustom.com on behalf of Alyxandra Davis Wednesday, October 16, 2019 8:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.            Due to unforseen complications in my own health TennCare has drastically saved my life and that of my child.     While I was pregnant it gave me the slightest hint of protection when it came to being a single mother trying to have a  child. It made sure my son was developing correctly. Without the insurance we had I could never afford to even have my  child let alone pay for every appointment and test we have to undergo as a soon to be mother.    It also DRASTICALLY  helps with my son. He is autistic. Due to his behavioral issues he has been kicked out of every  daycare and school I have tried to have him in since he was 6 months old.  This means I could no longer work to take  care of my child. Without tenncare we would have never got my son the help he needed and the help he still will need.  Being a single mother with no family to speak of I have no way of getting my son the basic insurance he needs even to  get his shots for school let alone if he was sick. He has therapys and other programs that he is in to help him which also  is included with his TennCare.     Thanks for listening. I hope this shows some light on how a parent of a disabilied child really cannot live without the  insurance he has.     21 Sincerely,  Alyxandra Davis  663 Freewill Rd NW Apt B Cleveland, TN 37312‐2451 alyxandradavis@yahoo.com  22 Jonathan Reeve From: Sent: To: Subject: beckijones77@everyactioncustom.com on behalf of Rebekah Jones Wednesday, October 16, 2019 9:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. It could completely destroy our home if we lose tncare/Medicaid. Our daughter  has Down syndrome, and has several health issues that are ongoing, and some will be life long. My husband and I also  live strictly on Medicare, and without Medicaid, I really don’t know what we would do. This is a very dangerous proposal  that could cause multiple deaths for people let without Medicaid.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rebekah Jones  4148 Oak Hills Rd  Parrottsville, TN 37843‐3242 beckijones77@yahoo.com  23 Jonathan Reeve From: Sent: To: Subject: rosalie3189@everyactioncustom.com on behalf of Rosalie Howes Wednesday, October 16, 2019 9:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I oppose this block grant bc it says specification on page 14, that the “state wants flexibility to EXCLUDE covering new,  and high cost prescription medications.” My child suffered a severe seizure disorder and for the first 3 years of his life,  he had multiple seizures a day, EVERYDAY! Then, finally an answer to a prayer, a new, and yes, pricey medication hit the  market. It saved my sons life. Now, 5 years later there is a generic form of that medication, but 5 years would have been  to late. New market medications can be the answer to a parents prayer for relief, and for their child’s life! What qualifies  legislators to say what is medically necessary? Determining medically necessary medications and procedures needs to be  left up to medical experts and doctors.  We need federal oversight of the Tenncare program because some legislators  would rather have extra funds in the savings account than to save the lives of our most vulnerable citizens.     Sincerely,  Miss Rosalie Howes  Lebanon, TN 37087  rosalie3189@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: dwjgdupre@everyactioncustom.com on behalf of Julia Dupre Wednesday, October 16, 2019 9:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TN Voter - Opposing the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I attended the public hearing today in Chattanooga and I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Julia Dupre  1044 Meadow Lake Rd  Chattanooga, TN 37415‐5606 dwjgdupre@aol.com  25 Jonathan Reeve From: Sent: To: Subject: baskerbubbles@everyactioncustom.com on behalf of Diane Jones Wednesday, October 16, 2019 9:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Diane Jones  590 Haynes Rd  Sewanee, TN 37375‐4015  baskerbubbles@yahoo.com  26 Jonathan Reeve From: Sent: To: Subject: katinab916@everyactioncustom.com on behalf of Katina Angola Wednesday, October 16, 2019 9:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Katina Angola  6044 Atkins Rd  Knoxville, TN 37918‐6032 katinab916@yahoo.com  27 Jonathan Reeve From: Sent: To: Subject: hstone501@everyactioncustom.com on behalf of Haley Stone Wednesday, October 16, 2019 10:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Haley Stone  Columbia, TN 38401  hstone501@gmail.com  28 Jonathan Reeve From: Sent: To: Subject: compton01@everyactioncustom.com on behalf of Mark Compton Wednesday, October 16, 2019 10:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant is an experiment that Tennessee doesn’t need   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    The legislature ofTennessee proposed this, but we are better off in this state following the rest of the nation. The  legislature here has enough on its plate addressing basic conflict of interest needs and inappropriate sexual misconduct  within its own body. Governor Bill Lee declared a day of prayer last week, for our state, and I did.    We should withdraw the request for a block grant which will harm the disadvantaged.    Sincerely,  Mark Compton  Greeneville, TN 37745  compton01@comcast.net  29 Jonathan Reeve From: Sent: To: Subject: kimpadula@everyactioncustom.com on behalf of Kim Padula Wednesday, October 16, 2019 10:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kim Padula  4812 Irving Ln  Nashville, TN 37214‐2776 kimpadula@gmail.com  30 Jonathan Reeve From: Sent: To: Subject: goedeckp@everyactioncustom.com on behalf of Patricia Goedecke Wednesday, October 16, 2019 10:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patricia Goedecke  1020 Meda St  Memphis, TN 38104‐5820  goedeckp@hotmail.com  31 Jonathan Reeve From: Sent: To: Subject: marthatsea@everyactioncustom.com on behalf of Martha Wettemann Wednesday, October 16, 2019 11:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Funding for Temporary Assistance to Needy Families (TANF) comes as a block grant to Tennessee. As a result basic  benefits to families have been frozen at the same level for 10 years or more. Can you imagine trying to raise a family on  a basic benefit of $189 a month? Block granting of this program reduced the value of the benefit due to a lack of  inflation adjustment, necessitating totally inadequate compensation for families and increasing pressures to remove  individuals from the program. It will be difficult to avoid these same problems with a Medicaid block grant.    TennCare has spent at least 10 years and more than $400 million on computer systems to operationalize the current  program. Will all that effort and expenditure be all for naught if TennCare changes to a block grant? What a waste of  taxpayers' money! How much will it cost to implement new programs for the new procedures, and where will the  money come from to do this?  I am also concerned about programs and vendors which have been excluded from the  block grant. On what basis was this decision made? I understand that when certain state services are privatized, like  services for those with intellectual disabilities, youth detention facilities, and adult correctional services, it is possible for  those individuals to receive TennCare under the auspices of private vendors, thereby passing the costs of medical care  onto the federal rather than state government. If we exclude these private vendors from the block grant, then not only  will the federal government pay fully for these services, but the vendors will continue to make a profit at the same time  other individuals may be losing healthcare services. For these and other reasons, I am opposed to the proposal to block  grant Medicaid/TennCare and urge that it not be implemented.     Sincerely,  Martha Wettemann  714 Darrow Drive, Pleasant View, Tennessee 37146    Sincerely,  Dr. Martha Wettemann  714 Darrow Dr  Pleasant View, TN 37146‐8073 marthatsea@comcast.net  32 Jonathan Reeve From: Sent: To: Subject: abat706@everyactioncustom.com on behalf of Angela Webb Wednesday, October 16, 2019 11:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Angela Webb  Kingsport, TN 37660  abat706@aol.com  33 Jonathan Reeve From: Sent: To: Subject: Kallie Goldman Wednesday, October 16, 2019 11:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Kallie Goldman   7376 Old Harding Pike  Nashville, TN 37221   34 Jonathan Reeve From: Sent: To: Subject: jebdeam@everyactioncustom.com on behalf of JANICE DEAN Wednesday, October 16, 2019 11:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Please do not change the way money is give to Tenn I have a grandchild that has a bad disease that can not have the money cut for his treatment . Care. Block grants will cause us to get less money for the sick. I have a grandson that has   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. JANICE DEAN  511 Carnation Ln  Mount Carmel, TN 37645‐3806 jebdeam@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: joanntroz@everyactioncustom.com on behalf of Joann Trozzo Wednesday, October 16, 2019 11:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joann Trozzo  918 Nottingham Dr  Cookeville, TN 38506‐4310 joanntroz@aol.com  36 Jonathan Reeve From: Sent: To: Subject: linda.halperin@everyactioncustom.com on behalf of Linda Halperin Wednesday, October 16, 2019 11:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Tennesseans are currently uninsured at an alarming rate!  Every politician says they will do something about it, but we  are still waiting.  This is not acceptable.     I am opposed to the proposal to convert Tennessee’s Medicaid (TennCare) into a “block grant.”  This proposal could  cause tremendous harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need.  This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations.  The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them.  The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less.  The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.   Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid.  This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver proposal goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go  forward with this harmful proposal.    Sincerely,  Dr. Linda Halperin  300 Turnberry Cir  Brentwood, TN 37027‐8240 linda.halperin@comcast.net  37 Jonathan Reeve From: Sent: To: Subject: alyssa.b.brandon76@everyactioncustom.com on behalf of Alyssa Brandon Wednesday, October 16, 2019 4:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Alyssa Brandon  2053 Hemlock Dr  Spring Hill, TN 37174‐2794 alyssa.b.brandon76@gmail.com  38 Jonathan Reeve From: Sent: To: Subject: karynjharris@everyactioncustom.com on behalf of Karyn Harris Wednesday, October 16, 2019 4:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I work with many who depend on TennCare.  I do not want them to lose benrfits .    Sincerely,  Karyn Harris  1829 Dunroamin Ln  Fayetteville, TN 37334‐3728 karynjharris@yahoo.com  39 Jonathan Reeve From: Sent: To: Subject: karynjharris@everyactioncustom.com on behalf of Karyn Harris Wednesday, October 16, 2019 4:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I work with many people who depend on tComment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Karyn Harris  1829 Dunroamin Ln  Fayetteville, TN 37334‐3728 karynjharris@yahoo.com  40 Jonathan Reeve From: Sent: To: Subject: karynjharris@everyactioncustom.com on behalf of Karyn Harris Wednesday, October 16, 2019 4:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I work with many who depend on TennCare. I do not want them to lose benefits.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Karyn Harris  1829 Dunroamin Ln  Fayetteville, TN 37334‐3728 karynjharris@yahoo.com  41 Jonathan Reeve From: Sent: To: Subject: melissa@everyactioncustom.com on behalf of Melissa Ann Roberge Wednesday, October 16, 2019 4:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] It is only human for a wealthy country to give access to good health care. Tennessee needs to support our people on Medicaid.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Melissa Ann Roberge  152 Read Trl  Rockvale, TN 37153‐5412  melissa@roberge.com  42 Jonathan Reeve From: Sent: To: Subject: abcarden52694@everyactioncustom.com on behalf of Aijahlon Carden Wednesday, October 16, 2019 4:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Aijahlon Carden  7115 Lenox Village Dr  Nashville, TN 37211‐7038 abcarden52694@gmail.com  43 Jonathan Reeve From: Sent: To: Subject: Caitlin Brooks Wednesday, October 16, 2019 4:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Caitlin Brooks   8211 Igou Gap Rd  Chattanooga, TN 37421   44 Jonathan Reeve From: Sent: To: Subject: Rain Fisher Wednesday, October 16, 2019 4:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Rain Fisher   2520 Devon Valley Dr  Nashville, TN 37221   45 Jonathan Reeve From: Sent: To: Subject: Halie Monroe Wednesday, October 16, 2019 5:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    PLEASE KEEP CF COVERAGE!!!!!   As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Halie Monroe   1735 Lascassas Pike Apt. 220  Murfreesboro, TN 37130   46 Jonathan Reeve From: Sent: To: Subject: Cheri detone Wednesday, October 16, 2019 5:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Cheri detone   1232 Timberwood Dr  Gallatin, TN 37066   47 Jonathan Reeve From: Sent: To: Subject: loganthompsonevents@everyactioncustom.com on behalf of Logan Thompson. Wednesday, October 16, 2019 5:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a single mother of a three year old daughter, I am opposed to the proposal to radically change Tennessee’s Medicaid  partnership with the federal government by converting federal funding for TennCare into a “block grant.” This proposal  would cause immense harm and jeopardize coverage for vulnerable Tennesseans including us. My daughters dad is not  involved in our lives, we get zero child support and I rely on TennCare to provide our health needs. I’m one of the lucky  mothers that has a healthy daughter but there are tons of families out there that couldn’t survive with out TennCare. I  hope everyone involved in trying to take this away never has to face one day where their health care is in jeopardy and  they are scared that they can’t provide care for themselves and their family. You should truly be ashamed.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Logan Thompson.  Spring Hill, TN 37174  loganthompsonevents@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: Ernest Escalera <5brokenstrings@gmail.com> Wednesday, October 16, 2019 5:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Ernest Escalera   108 Carls place  Ashland City, TN 37015   49 Jonathan Reeve From: Sent: To: Subject: Cynthia Willmon Wednesday, October 16, 2019 5:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Cynthia Willmon   1009 Renee Dr  Christiana, TN 37037   50 Jonathan Reeve From: Sent: To: Subject: Josh Ledbetter Wednesday, October 16, 2019 5:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Josh Ledbetter   1211 E Woodshire Dr  Knoxville, TN 37922   51 Jonathan Reeve From: Sent: To: Subject: nikkibautista87@everyactioncustom.com on behalf of Nikki Bautista Wednesday, October 16, 2019 5:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Nikki Bautista  6324 Mary Beth Ln  Harrison, TN 37341‐4937 nikkibautista87@aol.com  52 Jonathan Reeve From: Sent: To: Subject: Samantha DeTone Wednesday, October 16, 2019 5:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Samantha DeTone   353 Marrell St  Gallatin, TN 37066   53 Jonathan Reeve From: Sent: To: Subject: nikkibautista87@everyactioncustom.com on behalf of Nikki Bautista Wednesday, October 16, 2019 5:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Nikki Bautista  6324 Mary Beth Ln  Harrison, TN 37341‐4937 nikkibautista87@aol.com  54 Jonathan Reeve From: Sent: To: Subject: kkeele@everyactioncustom.com on behalf of Karen Keele Wednesday, October 16, 2019 5:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I am a former teacher. Let’s not continue to short change our children who don’t have the privilege of medical care. What a waste! I’   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Karen Keele  21 Poplar Ln  Sewanee, TN 37375‐2003  kkeele@sewanee.edu  55 Jonathan Reeve From: Sent: To: Subject: folkcnm93@everyactioncustom.com on behalf of Diane Folk Wednesday, October 16, 2019 6:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Diane Folk  2786 Lafayette Dr  Thompsons Station, TN 37179‐9759 folkcnm93@gmail.com  56 Jonathan Reeve From: Sent: To: Subject: bryndaquinn@everyactioncustom.com on behalf of Brynda Quinn Wednesday, October 16, 2019 6:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] As a provider for patients with Medicaid, I oppose a block grant   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Brynda Quinn  Nashville, TN 37127  bryndaquinn@hotmail.com  57 Jonathan Reeve From: Sent: To: Subject: Elizabeth Smith Wednesday, October 16, 2019 6:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Elizabeth Smith   4420 Thoroughbred Ln  Murfreesboro, TN 37127   58 Jonathan Reeve From: Sent: To: Subject: Savannah Smith Wednesday, October 16, 2019 6:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Savannah Smith   4420 Thoroughbred Ln  Murfreesboro, TN 37127   59 Jonathan Reeve From: Sent: To: Subject: amgrupke@everyactioncustom.com on behalf of Anna Grupke Wednesday, October 16, 2019 6:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Anna Grupke  Murfreesboro, TN 37129  amgrupke@gmail.com  60 Jonathan Reeve From: Sent: To: Subject: Brittain Adamson Wednesday, October 16, 2019 6:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Brittain Adamson   195 Melton Ln  Woodbury, TN 37190   61 Jonathan Reeve From: Sent: To: Subject: Eric Smith Wednesday, October 16, 2019 6:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Eric Smith   4420 Thoroughbred Ln  Murfreesboro, TN 37127   62 Jonathan Reeve From: Sent: To: Subject: Cherie Maynard Wednesday, October 16, 2019 6:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Cherie Maynard   3518 Richland Ave  Nashville, TN 37205   63 Jonathan Reeve From: Sent: To: Subject: Yvonne Salmon Wednesday, October 16, 2019 6:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Yvonne Salmon   505 E Gresham Dr  Smyrna, TN 37167   64 Jonathan Reeve From: Sent: To: Subject: cook0998@everyactioncustom.com on behalf of Anaiah Sierra Wednesday, October 16, 2019 6:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Anaiah Sierra  Bristol, TN 37620  cook0998@gmail.com  65 Jonathan Reeve From: Sent: To: Subject: akdalle.714@everyactioncustom.com on behalf of Anissa Dalle Wednesday, October 16, 2019 7:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans and it does not address the real problems we face regarding health care in our  state.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Anissa Dalle  5676 Quince Rd  Memphis, TN 38119‐7039  akdalle.714@gmail.com  66 Jonathan Reeve From: Sent: To: Subject: Daniel Goodman Wednesday, October 16, 2019 7:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Daniel Goodman   3069 Liberty Hills Dr  Franklin, TN 37067   67 Jonathan Reeve From: Sent: To: Subject: moonzmom@everyactioncustom.com on behalf of Connie Roe Wednesday, October 16, 2019 7:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Connie Roe  Blountville, TN 37617  moonzmom@hotmail.com  68 Jonathan Reeve From: Sent: To: Subject: jdbentley50@everyactioncustom.com on behalf of Joan Bentley Wednesday, October 16, 2019 7:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joan Bentley  Murfreesboro, TN 37127  jdbentley50@gmail.com  69 Jonathan Reeve From: Sent: To: Subject: Patricia Hudsmith Wednesday, October 16, 2019 7:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Patricia Hudsmith   286 Keswick Grove Ln  Franklin, TN 37067   70 Jonathan Reeve From: Sent: To: Subject: dennis03041963@everyactioncustom.com on behalf of Dennis McGuire Wednesday, October 16, 2019 7:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] CBlock grants are the last thing we need. Expand Medicaid and wait for your reimbursements like 49 other states. Transparency of fundsomment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dennis McGuire  PO Box 6131  Kingsport, TN 37663‐1131  dennis03041963@gmail.com  71 Jonathan Reeve From: Sent: To: Subject: true7thheaven@everyactioncustom.com on behalf of Tempest Melvin Wednesday, October 16, 2019 12:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. People I care about have multiple serious health conditions and rely on TennCare  for the doctors and specialists they have to see on a regular basis as well as for the cocktail of medications they have to  take to control their symptoms. They would not be able to afford their care without Medicaid. Even new restrictions to  Medicaid, like limiting the already limited number of prescriptions covered even more or removing some doctors from  network could severely impact their health and quality of life.    We need to be ensuring that the most vulnerable populations are able to get the treatment they need. Without it many  will suffer and could even die. We should be expanding Medicaid to cover more people not reforming it to cover less.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tempest Melvin  Cleveland, TN 37311  true7thheaven@aol.com  72 Jonathan Reeve From: Sent: To: Subject: robinjanejunebug@everyactioncustom.com on behalf of Robin Druliner Wednesday, October 16, 2019 12:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    STOP THE BLOCK!    Sincerely,  Robin Druliner  Kingsport, TN 37664  robinjanejunebug@gmail.com  73 Jonathan Reeve From: Sent: To: Subject: halfpeeledbanana@everyactioncustom.com on behalf of Annaruth McBride Wednesday, October 16, 2019 12:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Annaruth McBride  Nashville, TN 37205  halfpeeledbanana@gmail.com  74 Jonathan Reeve From: Sent: To: Subject: Rudy.flesch@everyactioncustom.com on behalf of Rudolf Flesch Wednesday, October 16, 2019 12:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    My wife and I have been raising grand children for over 20 years. We still care for two boys (Christopher Osias 14 and  Jeffrey Flesch, 13) who both are in the autism spectrum.     Raising our 6 grandkids without financial help from their parents has depleted our savings and we now subsist on our  Social Security incomes. I have been working as a teaching assistant At our local High School. At age 80 it is now getting  to be too much for me to continue working. It is, therefore, crucial that the two boys stay covered by Tenncare.    As a result I am strongly opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Rudolf Flesch    Sincerely,  Rudolf Flesch  2337 Floyd Porter Rd  Maryville, TN 37803‐9407 Rudy.flesch@gmail.com  75 Jonathan Reeve From: Sent: To: Subject: ashfordsadia@everyactioncustom.com on behalf of Sadiatou Jallow Wednesday, October 16, 2019 12:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] This is what kids and adults need to survive! They all need Medicaid for their medical health care needs! Therefore, please, please, please, do not put a block on Medicaid/ Tenncare grants! Think about these people of Tennessee and not the m...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Sadiatou Jallow  226 Oran Rd  Knoxville, TN 37934‐1819  ashfordsadia@gmail.com  76 Jonathan Reeve From: Sent: To: Subject: Tim French Wednesday, October 16, 2019 12:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Tim French   140 Noya Trace  Loudon, TN 37774   77 Jonathan Reeve From: Sent: To: Subject: Donna French Wednesday, October 16, 2019 12:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Donna French   140 Noya Trace  Loudon, TN 37774   78 Jonathan Reeve From: Sent: To: Subject: maprisco1@everyactioncustom.com on behalf of Mary Prisco Wednesday, October 16, 2019 12:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Mary Prisco  1802  Nashville, TN 37206  maprisco1@gmail.com  79 Jonathan Reeve From: Sent: To: Subject: bobrowlett@everyactioncustom.com on behalf of Brenda Rowlett Wednesday, October 16, 2019 1:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Brenda Rowlett  Smyrna, TN 37167  bobrowlett@msn.com  80 Jonathan Reeve From: Sent: To: Subject: kimberly37660@everyactioncustom.com on behalf of Kim Murphy Wednesday, October 16, 2019 1:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kim Murphy  Kingsport, TN 37660  kimberly37660@aol.com  81 Jonathan Reeve From: Sent: To: Subject: bbblueeyes77@everyactioncustom.com on behalf of Anna Hackler Wednesday, October 16, 2019 2:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Anna Hackler  280 Old Watauga Rd  Elizabethton, TN 37643‐6669 bbblueeyes77@icloud.com  82 Jonathan Reeve From: Sent: To: Subject: tyturleytrejo@everyactioncustom.com on behalf of Ty Trejo Wednesday, October 16, 2019 2:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, like me and my family.    We are recent transplants from Colorado and are attending Vanderbilt Law School. I have a pre‐existing chronic  condition that requires life‐preserving medication, and as a husband and father of two kids under two with little‐to‐no  income, we rely on wonderful programs like Medicaid. My wife stays home to take care of our two children and  thankfully has a job that allows her to work remotely (during nap times), but other than that, with my full‐time  responsibilities as a student we cannot afford health insurance. We already had to go without health insurance for the  first two months of the 2019‐20 school year (because it took that long to be approved with TennCare) and I can't tell you  how terrified my wife and I were every time we got into the car, or took our kids to the playground, or heard a slight  cough in our 3‐month old. What if something happened and we didn't have any insurance? Would our kids be taken care  of? Would we be saddled with crippling health bills? My 2‐year‐old suffered a febrile seizure almost a year ago and we  were beyond grateful to have health insurance. That is exactly what it's for. And it would be a travesty if TN passes laws  that jeopardize families like mine in getting coverage.     We are staunch conservatives and don't love relying on the government, but we are so grateful to rely on Medicaid for  just a few years until I can get a job with health insurance. I never thought I would need Medicaid. Sometimes I'm  embarrassed to mention that we rely on Medicaid, but I realize now how everyone needs a hand up every now and  then.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Ty Trejo  Nashville, TN 37221  tyturleytrejo@gmail.com  83 Jonathan Reeve From: Sent: To: Subject: blazingbill11@everyactioncustom.com on behalf of William Sera Wednesday, October 16, 2019 3:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] The Realistic Solution to Medicaid Block Grant   Dear Gabe Roberts,    Good afternoon ladies and gentlemen,    My name is William "Bill" Sera. I am a courtesy clerk at Food City who works three days a week. I have Asperger's  Disorder, on the Autism Spectrum Disorder, and I am on the high end. I also have Bipolar Disorder and PTSD. Since I am  working at Food City, I am part of the Disabled Working Class. And as all workers, we pay our taxes to contribute to the  system. There also working class citizens who have children. There are also people with disabilities who have  contributed to the system, such as veterans, and people who were able to work before becoming too disabled.    I am neither a pessimist nor an optimist. Whatever happens is going to happen. But all the people who have contributed  or who are contributing should continue getting their benefits. For those who don't want to work or won't work, they  should be given the ability to join programs to help them find jobs. People who want to work and are struggling to find  work should be allowed to keep their benefits. People who are too disabled to work should be able to access benefits as  well. And no child should be denied healthcare.    I am a member of the IPS Advisory Steering Committee at the AIM Center, which is one of those places where people  with mental disorders can find work. I propose that we go out and do outreach to encourage people to work so they can  get into the system and keep their benefits. If they try for three months and cannot find work, they should be able to  keep their benefits.    This way we can weed out the ones who might be committing TennCare fraud without hurting the ones who aren't.     Thank you for your time and consideration.    Sincerely,  William Sera  3806 Mission View Ave Apt 102A Chattanooga, TN 37411‐5132 blazingbill11@yahoo.com  84 Jonathan Reeve From: Sent: To: Subject: jaredpsmom@everyactioncustom.com on behalf of Robin Parrott Wednesday, October 16, 2019 3:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Robin Parrott  2604 Stoner Rd  Sevierville, TN 37876‐2304 jaredpsmom@yahoo.com  85 Jonathan Reeve From: Sent: To: Subject: Lee White Wednesday, October 16, 2019 3:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Lee White   1044 PERCY WARNER BLVD  Nashville, TN 37205   86 Jonathan Reeve From: Sent: To: Subject: Stephendick24@everyactioncustom.com on behalf of Stephen Dick Wednesday, October 16, 2019 3:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Stephen Dick  610 Greenwood Dr Apt 25 Athens, TN 37303‐4748 Stephendick24@yahoo.com  87 Jonathan Reeve From: Sent: To: Subject: Stephendick24@everyactioncustom.com on behalf of Stephen Dick Wednesday, October 16, 2019 3:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Stephen Dick  610 Greenwood Dr Apt 25 Athens, TN 37303‐4748 Stephendick24@yahoo.com  88 Jonathan Reeve From: Sent: To: Subject: Steve Rainey Wednesday, October 16, 2019 3:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Steve Rainey   548 Bryan Rd  Clarksville, TN 37043   89 Jonathan Reeve From: Sent: To: Subject: Donna Rainey Wednesday, October 16, 2019 3:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Donna Rainey   548 Bryan Rd  Clarksville, TN 37043   90 Jonathan Reeve From: Sent: To: Subject: msnullins77@everyactioncustom.com on behalf of Marsha Mullins Wednesday, October 16, 2019 3:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.   My 91 year old mother relies on this for her medical needs.  I also have another  family member who is a working, single mother with three children who are depending on this to supplement the  insurance she has at her job.   It is imperative that they and others retain these funds.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marsha Mullins  Kingsport, TN 37665  msnullins77@hotmail.com  91 Jonathan Reeve From: Sent: To: Subject: Jeff Lemon Sunday, October 20, 2019 11:09 AM PUBLICE NOTICE TENNCARE; rep.robin.smith@capitol.tn.gov; Bo Watson [EXTERNAL] Gov. Lee's Block Grant Proposal for TennCare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Greetings! My apologies for contacting you on two separate issues on the same day, but, I am concerned over Governor Bill Lee's block grant proposal for TennCare. Simply put, too many Tennesseeans are being deprived of the care and coverage they need, and his experimental proposal could make things worse for families across the state. Right now, there are 675,000 Tennesseans who go to bed each night without health insurance 20,000 of them are here in Chattanooga. There are 65,772 Hamilton County residents enrolled in TennCare. Nearly 90% are women and children. The remainder are nearly all elderly, blind, or have severe disabilities. Under Governor Lee's "modified" block grant, the State will continue to get funding from the federal government as membership grows -- but if TennCare spends less than the federal government gives it, Tennessee state government can keep half of the extra money. This means that the state government, which already provides among the stingiest benefits to the working poor, will have an incentive to cut those benefits even further. This is simply unacceptable. When I talk to my neighbors, they tell me about the things that actually worry them: the rise in the number of people who are uninsured, despite working as hard as they can. The opioid crisis. Growing medical debt. The constant fear of losing coverage because of pre-existing conditions. I have yet to hear a single person tell me that they worry about how much money state bureaucrats could save by cutting health coverage for Tennessee's most vulnerable families! Please do not support this proposal. Thanks! Jeff Jeff Lemon 6673 Bucksland Drive Ooltewah, TN 37363 92 93 Jonathan Reeve From: Sent: To: Subject: Angela Wittenberg Sunday, October 20, 2019 9:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Why???   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   What possible benefits does this provide for Tennessee taxpayers and citizens? We need more healthcare services, not  less. Please do not support this block. We have a wonderful State! Let’s have wonderful healthcare for all volunteers.    Angela W  Ashland City   94 Jonathan Reeve From: Sent: To: Subject: Andrew Ward Saturday, October 19, 2019 8:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am absolutely against this.     Andrew B Ward  Goodlettsville TN  95 Jonathan Reeve From: Sent: To: Subject: Pat Ralston Saturday, October 19, 2019 12:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] NO block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I have been reading about the proposed Block Grant and I can see no real benefit the Tennesseans.  Most of your town  hall meetings have shown that very few Tennesseans want the Block Grant.  Do not go forward with this plan.    ‐‐     Pat Ralston  brimerpbr@gmail.com  96 Jonathan Reeve From: Sent: To: Subject: Kay Grossberg Saturday, October 19, 2019 10:02 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Proposed Block Grant for TennCare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   This may be too late, but I would like to add my concerns about the block grant proposal for TennCare.  I am concerned  that the proposal is requesting to be released from federal oversight and accountability with regard to the TennCare  program. I am concerned that this may affect poor children and elderly.    Sincerely,  Kay Grossberg  Voter      97 Jonathan Reeve From: Sent: To: Subject: CD Pritchard Saturday, October 19, 2019 7:10 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on Amendment 42, TennCare block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Comments on Amendment 42, TennCare block grant. I greatly distrust any medicaid/TennCare changes by a state that has refused to expand medicaid via the Affordable Care Act. Under that program, Tennessee would be able to cover hundreds of thousands more citizens with the Federal government paying 90 percent of the cost- an estimated additional $1.4 billion per year! The fact that 36 other states have adopted this program, have covered more of their citizens, have gotten back more of their (and also Tennessee!) citizens federal tax dollars and none have withdrawn indicates that it is highly successful. Instead, a likely illegal pie-in-the-sky block grant is proposed. The wavier goes against the objectives of Medicaid because it gives Tennessee new authority to cut services without federal oversight or even public notice. Over the past two years, TennCare has cut off over 200,000 children- most of whom were still eligible. Then they erred in having money taken out of poor seniors their Social Security checks- folks who are barely squeaking bay without such screw-ups. Such an administration should not be allowed any additional flexibility. Governor Lee has said the waiver could result in Tennessee collecting as much as $1 billion in savings each year. That is far-fetched without dire cuts in health care. It has also been promised that the saving will be invested in TennCare. This I do not believe. What happens if an emergency occurs like the flu pandemic 1918 strikes and health demands skyrocket? Since federally payments are in effect capped, either the state will have to pay more than it would under the current system, hope for at least partial federal reimbursement under some future legislation (highly unlikely…) or- much more likely- cut health care. The allusions to targeting populations and improving rural health care are ominous. It strikes me as just another way to engage in porkbarrel type politics. The proposal relies on a CMS wavier pursuant to section 1115 . That section lists the other sections that can be waived. Section 1903 which mandates the current funding formula is not listed. This prohibits block grants. If the proposal is approved, CMS will be sued and CMS will very likely loose based solely on mere reading of the law. Tennessee will likely be caught in the middle of this fiasco and poor Tennesseans whip-sawn in the process. The only way I would acquiesce to the proposal is if all Gov. Lee, all state legislators who voted for requiring the the waiver and the top TennCare executives are required to rely solely on the hacked TennCare for their and their families health care. C.D. Pritchard 9110 Potomac Dr. Chattanooga, TN  37421        98 Jonathan Reeve From: Sent: To: Subject: Albron Hana Saturday, October 19, 2019 6:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Porposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am writing on behalf and in support of the block grant bill to be passed .    It has been proven, time and time again, over the last century, that the more the federal government administers, the  more waste that is created.     I’d much rather have my local state government in charge of these funds .     Our elected officials that know our local and state needs are a much better choice than any bureaucrat sitting in  Washington .    I moved here from Illinois last year because of the poorly advised policy making that has led to unsustainable Cost of  living due to high taxes .     Don’t be the next Illinois. Broke and a joke .    Albron Hana   305 Duke st #B  Nashville, TN 37207  312‐975‐3717  99 Jonathan Reeve From: Sent: To: Subject: Scherry Fouke Friday, October 18, 2019 11:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Waiver Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Gabe Roberts, Director   Division of TennCare      RE: TennCare Waiver Amendment 42     Dear Mr. Roberts,      I am writing to indicate my strong opposition to Governor Lee’s Block Grant proposal.     Though now retired as a priest in the Episcopal Church, I spent 35 years involved in active parish ministry. That ministry  directly involved serving the pastoral needs of all ages and constellations of people: children, adults, and the elderly;  single, married, divorced and widowed or widowers; people with chronic conditions, addictions, disabilities and  limitations; the working poor, families in which both parents worked and I have also been involved with those who could  well afford healthcare for any concern they had.      I can share story after story of how addiction upends families, throwing them into chaos; how some of my elderly  diabetic parishioners were forced to choose between eating and having their medication.  I know all about people who  don’t see doctors or have treatment because they have no health insurance and have used the emergency rooms of  area hospitals for an acute health episode.      According to the US Census Bureau, I live in a community in which 60% of the children in school get two meals a day at  school. In my town, 22% of the inhabitants fall under the poverty level.      According to the Institutes for Health Metrics and Evaluation, tracheal, bronchus and lung cancer in women has  increased by 124% in my county between 1980‐2014; mental health issues and addiction in women has increased  1,146.5% since 1980.  In Hamblen County, women’s all‐cause mortality rate is 33% higher than the national average;  diabetes, urogenital, blood and endocrine disease mortality among women is 42% higher than the national average.      In Hamblen County, life expectancy for men is 73% of the national average; cerebrovascular disease is 59% higher than  the national average. Heart disease among men in my county is 34% higher than the national average; tracheal bronchus  and lung cancer in men in my county is a whopping 77% larger than the national average; diabetes mortality in men is  41% higher than the national average and mental and substance abuse disorders is 75% higher than the national  average, cirrhosis and other chronic liver disease mortality is 68% higher than the national average.       All these conditions require long‐term, expensive treatment. These numbers are replicated throughout this state. If the  General Assembly had voted to expand Medicaid, some 300,000 citizens, working people, families, the poor and the  elderly of this state would have been helped. But the General Assembly did not support the expansion of Medicaid. It  did not support Governor Haslam’s plan to address healthcare needs either.      100 Instead, this state has done little. The result is that the mortality rate, substance abuse, diabetes and obesity rates have  risen. In a time of increasing need for medical care, one would expect legislators and elected officials to be searching for  ways to respond.  On the contrary: Tennessee has the highest per capita rate of rural hospital closures in the nation. One  of those hospital closings took place in my county last December.      Instead of seeking ways to help, the state has engaged in a practice of dropping children from the Tennessee rolls  without notice. In the last two years, 200,000 children have been dropped. The majority of those are still eligible for  coverage. Some of those children have been re‐enrolled and we have heard about failures within the records of the  delivery system as being the cause.     One may draw three conclusions from this information:      1. Our state is in dire need of improving access to healthcare for the thousands who need it. That improved access  must include the facilities, the staff and some sort of coverage that can assist those who need those services.  2. The second conclusion to be drawn is that our General Assembly cannot be trusted to make decisions which  serve the needs of its citizens. The state is either unable or unwilling to design, to employ and/or to provide the  structures and oversight needed to govern them.   3. The third conclusion that can be draw from looking at this situation is that Tennesseans, in large numbers,  do  not make the kinds of choices they need to make to stay healthy. The block grant proposal does not indicate that the  state is willing to educate and/or reward people for taking preventive measures in guarding their health. The usual  position taken by the General Assembly on healthcare issues has been largely punitive. Will that predisposition to  punish be the guiding principle on administering the block grant?     Since taking office, Governor Lee has put forward two proposals to address the healthcare issues of this state. The first is  to have a state supported, faith‐based response to issues like addiction. That’s another letter; not this one.      The focus of this letter is on the “block grant” proposal that would convert federal funding for TennCare into a lump sum  payment of federal monies of $7.9B to be administered by a state of Tennessee agency.      Governor Lee’s reasons for proposing this measure are:      1. He believes that Tennessee has demonstrated that it can save the federal government money in health care.  How? Thus far, saving money has meant removing people from the rolls, closing rural hospitals, and by reducing  subsidies on physical therapy, hospice and medication.  2. He believes that Tennessee is equipped and capable of providing a structure and oversight for sustaining a  “block grant” The evidence points in the opposite direction.  a. The plan as presented does not indicate what kind of structure is envisioned and/or how it would be  overseen.   b. Would the money be allocated by the General Assembly to programs already in existence?  c. Or will there be a special and different program charged with delivery of this $7.5B? If this is the answer  then money for the programs, facilities and staffing would come out of the $7.5B as administrative expense.  That is not helping, it is merely duplicating federal services already in existence.   3. Gov. Lee proposes that if there are ”savings” in this program, those “savings” would be equally split, ½ being  retained by the state and ½ being returned to the federal government. The program proposal can only be  interpreted in one way, then.  Namely, the “block grant” request is not a request grounded in helping sick people:  the proposal is merely a request for the state to be the administrator of federal money. The assurance given is that it  will result in “savings” for the federal government.      I am opposed to this plan because it has little to do with healthcare. This is a plan focused on how to take advantage of  federal money.  It is flawed in its purpose and inadequate in demonstrating any planning.       I urge you and others to stop this proposal in its tracks.   101    If Governor Lee wishes to address the lack of healthcare in Tennessee and the capacity of this state to manage its  healthcare program for all, then his proposal needs to reflect deeper, healthcare rationale. It needs to show key  elements of planning and oversight and how it will help Tennesseans get the care they need.      Thank you for receiving this.     Sincerely,      The Rev. Scherry Fouke    The Rev Scherry Fouke  1601 Forest Drive  Morristown, TN 37814    Email:  revsvf@gmail.com  Cell Phone: 423‐736‐6407  Fax: 423‐581‐5369  102 Jonathan Reeve From: Sent: To: Subject: Flanagan Friday, October 18, 2019 10:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] proposed block grant funding of medicaid   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***     Dear TennCare officials, TennCare is important to my daughter Kayli Flanagan. It provides comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare has helped Kayli access the treatment, both psychological and psychiatric that she requires to live. Our daughter became disabled at age 15. Without TennCare to provide for medical services, she’d be dead by now. Once she became 18, and still hospitalized, we, my wife and I, had to trouble accessing services for her as her disability status had changed due to her age. TennCare helped us with that transition. We couldn’t have done it without that program. After years of hospitalizations, we finally went to Vanderbilt because the hospitals: Peninsula, and Woodridge, in NE Tennessee had only resulted in having our daughter moved to the emergency room at Park Ridge and Johnson City Medical Center, respectively, for life-threatening “Failure to Thrive”. Vanderbilt was able to stabilize her and provide the correct “cocktail” of medicines that enabled her to return to reality. We are forever grateful. Two of the three medicines are costly. Clozaril, and Trileptal; two medicines that have been around for a long time, yet the cost is really high. Much higher than you would believe. We’ve tried the generic formulations, they didn’t work. She, Kayli, wound up back at the hospital, and then to the Crisis Stabilization Unit. Kayli is now 29. Her mother and I, still married, are her conservators. I looked into why the generic formulations were not as effective as the original medication and was dismayed to find out that a generic formulation of the medicine didn’t need to have the same amount of active ingredient, nor the same quality, (qualitative and quantative analysis) but only be within a percentage of the product. I would urge you to consider the millions of dollars saved if generics had to have the same amount of active ingredient as the original product. I would use the analogy of buying a can of peas that contained a dozen peas within the can. Generics would work, were they formulated with the same amount and quality of medicine the original product was labeled with. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely, John and Linda Flanagan 103   104 Jonathan Reeve From: Sent: To: Subject: Paige Friday, October 18, 2019 10:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Public comments *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. *** I am a Tennessee citizen and I am against the block grant proposal. Medicare expansion would solve many of our states medical problems and keep people healthy. Please save your citizens and the rural hospitals, don’t make the problem worse by changing to the block grants. Paige Silcox Registered Voter 105 Jonathan Reeve From: Sent: To: Subject: Paulson, Alexis Bartley Friday, October 18, 2019 10:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I am writing to express my concern over the block grant proposal for Medicaid. It will threaten the health coverage of  my patients and the most vulnerable families in Tennessee.     Thank you.     Alexis Paulson, MSN, APRN, WHNP‐BC  Radiology Nurse Practitioner  Vanderbilt University Medical Center.     106 Jonathan Reeve From: Sent: To: Subject: Virginia Vagt Friday, October 18, 2019 10:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I'm opposed to Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Re: TennCare II Demonstration, Amendment 42    I am not in favor of Amendment 42. Instead, I am in favor of improving the waiver in ways that will expand Medicaid in Tennessee.     Please do not pass or submit a request for this Amendment 42.     Amendment 42 proposes a dangerous experiment that threatens health coverage for the nearly 1.4 million people in Tennessee who rely on Medicaid. Furthermore, it does nothing to expand coverage to the 675,000 Tennesseans who still do not have any health insurance.     This amendment will doom more people in Tennessee to die and suffer, unnecessarily, because it will allow our state to not expand Medicaid here in Tennessee. In proposing this Amendment those who propose it are saying, in effect, “We’re fine with children being more likely to die here in Tennessee than in 40 other states in America."    In the words of our good US Congressman, Jim Cooper, who opposes Amendment 42:     “What if you are one of the two million Americans who suffer opioid abuse? There’s hope if you live in a state that expanded Medicaid where access to treatment centers have led to fewer overdoses. But in Tennessee, more of our people are overdosing. And what about the health of mothers in Tennessee? Of all of the maternal deaths in 2017, 85% were preventable. Think about that – many of these mothers might still be alive if Tennessee had only treated them better by expanding Medicaid.”    People in Tennessee who need Medicaid are people with worth and dignity, just like the people of Tennessee who do not need Medicaid. I’m in favor of helping more people who need it have access to the health care that Medicaid provides.   1   Thank you for asking for my view of Amendment 42.     Virginia Vagt  Nashville, TN       2 Jonathan Reeve From: Sent: To: Subject: Lisa Bennett Friday, October 18, 2019 9:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear TennCare officials,    TennCare is important to me and my family, particularly my daughter who suffers from mental illness. It provides  comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with  mental illness, many of whom rely on it to access essential health treatments and manage their condition.  TennCare has  helped my family by providing mental health coverage for my daughter.     I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal  would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this  proposal would allow the state to eliminate or restrict services that are important to people with mental illness.      More people need access to TennCare, not less.      I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not  hurt them.      Sincerely,  Lisa Bennett    Sent from my iPad  3 Jonathan Reeve From: Sent: To: Subject: Aaron Oates Friday, October 18, 2019 9:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicare Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I do not support block grants for Medicare. It does nothing to provide expanded coverage for the thousands of people in  TN without coverage, and is inadequate  4 Jonathan Reeve From: Sent: To: Subject: pelaynep@everyactioncustom.com on behalf of P Elayne Poston Friday, October 18, 2019 9:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     My concern is what happens to the Elders? I know that Long‐Term Care has a carve out in Tenn‐Care. However, what  about that person that no longer qualifies for benefits yet they don't qualify for Skilled Nursing Care?  What happens to them?     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.        Sincerely,  P Elayne Poston  3879 Lost Shadows Cv  Memphis, TN 38128‐2416 pelaynep@gmail.com  5 Jonathan Reeve From: Sent: To: Subject: Michael Kress Friday, October 18, 2019 8:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am against the block grant.  6 Jonathan Reeve From: Sent: To: Subject: rwspry@everyactioncustom.com on behalf of Richard Spry Friday, October 18, 2019 8:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.”     I have friends, a family of 7, who depend on TennCare. Losing benefits would be devastating to them.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.    I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Richard Spry  2414 Spaulding Cir  Murfreesboro, TN 37128‐4823 rwspry@gmail.com  7 Jonathan Reeve From: Sent: To: Subject: Robin Nobling Friday, October 18, 2019 8:05 PM Lynn Fritz; PUBLICE NOTICE TENNCARE [EXTERNAL] Re: Comment on proposed TennCare Medicaid block grant waiver   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Looks great Lynn. Let's hope it's given an honest review. Robin Get Outlook for Android From: Lynn Fritz   Sent: Friday, October 18, 2019 1:28:44 PM  To: public.notice.tenncare@tn.gov   Subject: Comment on proposed TennCare Medicaid block grant waiver      Dear TennCare officials, As a Legislative Advocacy Volunteer for NAMI Davidson County, I am very concerned about the plan to convert the TennCare Medicaid program to a “block grant,” for a number of reasons: Tennessee currently ranks poorly in many measures of health care. Note the following statistics: - Tennessee’s health care ranked #43 in the nation in 2018. (source: U.S News & World Report) - Tennessee’s rate of uninsured residents rose by .6 percent in 2018, representing about 46,000 more Tennesseans without health insurance (Tennessean article, September 11, 2019) and tying for the third-largest rate increase nationwide as one of only 9 states to see their uninsured rate grow in 2018. (source: U.S. Census Bureau report, September 2019). According to the Census Bureau cited in the Tennessean article of September 11, “The Census Bureau now estimates that more than 675,000 Tennesseans – or about one in 10 state residents – have no insurance coverage.” - At the same time as our rate of uninsured residents increased, the proportion of people living under the federal poverty line increased from an estimated 15 percent in 2017 to 15.3 percent in 2018. (source: U.S. Census Bureau report, September 2019) When looking specifically at mental health, according to an analysis by Mental Health America quoted in a November 19, 2018 article in the Tennessean, Tennessee ranked 16thin the 8 prevalence of mental illness but 46thin access to mental health care, and only one other state has a larger proportion of adults with mental illness who are uninsured. Tennesseans place great value on the importance of health care, with health care emerging as the top concern of voters in Vanderbilt University’s public policy poll in late 2018. This same poll also showed that 66% of registered voters in Tennessee favor Medicaid expansion. Our new governor, Bill Lee, has listed Mental Health among his top five funding priorities. Given the importance placed on health care by Tennessee residents and the poor state of our health care, now is the time to provide more resources for the health care of our most vulnerable citizens. The block grant proposal, however, seeks to extract $2 billion from Tennessee’s Medicaid system to provide the state with $1 billion in funds to be used by the state in undefined ways, unrestricted by federal standards. To achieve these funds, the proposal suggests, for example, TennCare may only cover one drug in a class. For patients who are seeking to manage a serious mental illness, finding a drug that will effectively control and manage their illness and that will have tolerable side effects very often requires trying different medications and dosages and combinations. Covering only one drug will have seriously detrimental effects on the health of this vulnerable population. Ineffective treatment leads to destabilization of the individual’s mental health condition. The domino effect then leads to higher rates of crisis treatment service utilization, as noted by the Tennessee Department of Mental Health and Substance Abuse Services own Databook over the last 3 years. Savings are not realized. Also, these individuals are more likely to come in contact with the justice system. Concentrated efforts have been made for the last three years, across the state of Tennessee, by coalitions of providers, mental health advocates, law enforcement, justice and homeless representatives to divert people with mental health issues away from the justice system and into care. Limiting treatment options in a one-size-fits-all formulary is short-sighted, costly and inhumane. The block grant waiver proposal seeks to eliminate federal minimum standards and patient protections. Giving free rein to the state and its managed care contractors opens the door for corruption and abuse of the system. Unfortunately, Tennessee has already experienced corruption of this sort 20 years ago, and our state’s past shows the necessity of federal standards and safeguards. By removing the requirement for Tennesssee to follow the federal government’s list of optional and mandatory services, this proposal would allow for rationing of health care to save money. Given that patients needing mental health care have required parity laws to receive medical treatment equal to physical conditions, the possibility of state-determined cuts to services is a scary prospect indeed – whether these cuts come via elimination or restriction of services and levels of care, or limitations in drug choice or coverage or length of stay in care facilities, or via cuts in payments to providers. 9 The block grant waiver proposal does not provide for a well-structured and defined appeals process for patients. At the same time that there is a possibility of patients’ health care being rationed, there is no system for patients to appeal coverage decisions or denials of services. A further suggested way of saving money is to institute copays for TennCare participants. This, along with forcing enrollees to pay the full cost of prescriptions that would no longer be covered will place a further financial burden on already vulnerable populations. In addition, as the state acknowledges, “TN operates one of the most cost-effective Medicaid programs in the nation.” This lean operation makes it apparent that achieving the desired further cost savings will require cuts in the amount of care a patient will receive. TennCare has not shown that it has the systems and infrastructure to be entrusted with implementing a block grant. The past several years have included: significant problems with the rollout of their computerized TEDS system (incurring $400 million in cost overruns), the resulting difficulty of enrolling or renewing enrollment, and the inexplicable removal with no prior notice of upwards of 200,000 children, many of whom were still eligible for coverage. This track record indicates a lack of preparedness to be the first state to attempt a block grant program. Our residents, given the poor state of our health care, can ill afford being the subjects of this block grant experiment. I attended the block grant hearing in Nashville on October 1st. In a large full room of over 150 people, I listened as speaker after speaker spoke in opposition to this block grant proposal. Speakers opposed included Representative Jim Cooper, two pediatricians from the Tennessee chapter of the American Academy of Pediatrics, a nurse practitioner and clinic volunteer from rural Tennessee, a retired nurse practitioner who worked at the Department of Health and had witnessed the effects of the 2005-2008 period of TennCare disenrollment, the state director of the Tennessee Small Business Alliance, a legally blind senior TennCare enrollee, a representative of the Tennessee Primary Care Association of Community Health Centers, a family physician, NAMI Tennessee’s Executive Director as well as Advocacy Director, a Tennessee Justice Center and Tennessee Health Care Campaign volunteer, a pastor and father of an intellectually disabled son, the Director of Advocacy of the American Lung Association, the founder of TN Holler, a mom of a seriously ill daughter and TennCare enrollee, a social worker, an attorney with the Legal Aid Society of Middle Tennessee, the CEO of Mental Health America of Mid-South, a representative of AARP, a neuroscientist with a son with a rare brain disorder, a retired public health nurse, the Executive Director of the Tennessee Justice Center, a senior citizen who had lost her TennCare coverage due to problems with paperwork, a behavioral analyst who provides services for TennCare, and several citizens concerned about justice and various aspects of health care. Not one person in attendance, representating such a broad spectrum of health care stakeholders and interested cititzens, spoke in favor of the block grant. 10 In comments after the hearing, Governor Bill Lee expressed that those who oppose the block grant fail to fully understand the complex proposal. The plan, however, is woefully lacking in detail. This lack of detail makes it impossible to support this plan. As the parent of an adult child who is living a very successful recovery with a serious mental illness, I know first-hand the importance of investing in quality treatment over a period of time. I know from our family’s experience that an investment in quality crisis care, in appropriate medications, in quality treatment for an appropriate period of time EARLY is exactly what is needed to promote health and prevent much greater costs in the future. Our daughter is now able to live independently, owns her own home, has a good job, and is a taxpaying contributor to our state. Without quality treatment, her positive outcome would not have happened, and our family would have incurred much greater health care costs over time, with the very real possibility of repeated crises and hospitalizations. Rather than looking to find ways to remove funds from TennCare, our state should be looking for ways to add funds. I can’t think of a more worthy budget priority than investing in the long-term health of Tennesseans. Please reconsider this proposal and instead of looking to take money out of TennCare, look for ways to more fully fund health care in our state so that we can rise to the top in health care rankings, instead of bringing up the rear. Sincerely, Lynn Fritz NAMI Davidson County, Legislative Policy Volunteer  11 Jonathan Reeve From: Sent: To: Subject: ml.horton@epbfi.com Friday, October 18, 2019 7:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the block grant. It is inconceivable to expect success by replacing the flawed Tenncare program with one that would provide less oversight and incentivize the state to pursue further cuts resulting in increased revenue for the state. The solution to this health care problem is obviousexpand Medicaid under the ACA. Marshall Horton MD 12 Jonathan Reeve From: Sent: To: Subject: tanyatull@everyactioncustom.com on behalf of Tanya Tull Friday, October 18, 2019 6:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tanya Tull  62 Condo Ln  Counce, TN 38326‐4633  tanyatull@icloud.com  13 Jonathan Reeve From: Sent: To: Subject: Jacqueline Woodward Friday, October 18, 2019 7:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Please withdraw your request to change TN Care into a program funded by a block grant.  We are concerned that the  block grant would adversely affect the medical care that our adult daughter is receiving.  She has schizophrenia and  obsessive compulsive disorder.  With regular care from her psychiatrist and effective medications, she has been able to  hold the same job for 25 years.          Thank you for considering our request that The good care she has received from TN CARE not be disturbed by a block  grant.             Sincerely yours,             Jacqueline J. WOodward           STephen C. Woodward, M.D.  14 Jonathan Reeve From: Sent: To: Subject: B W Friday, October 18, 2019 7:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Reject it   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I’m shocked this would even be proposed   Why is there always a Scamm with anything that’s introduced.  These politicians are eating to high on the hog and can’t see daylight.  Reject it,  Beverly   15 Jonathan Reeve From: Sent: To: Subject: Kay Kress Friday, October 18, 2019 7:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] blockgrant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Tennesseans need health care not Gov. Lee's block grant.  16 Jonathan Reeve From: Sent: To: Subject: Stephen Kress Friday, October 18, 2019 7:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   The working poor deserve better. No on the block grant. Yes on expanding Medicaid.  17 Jonathan Reeve From: Sent: To: Subject: Donofrio, Peter (University) Friday, October 18, 2019 6:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant for Tennessee Medicaid   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   My wife and I are opposed to the block grant proposal for Medicaid.  It is a very bad idea as it will ultimately  compromise health care for the indigent and poor.  The block grant does not make sense for the state of Tennessee. We  do not need to save money for this program. We need to expand it to cover more people who are on the margins on our  society.  We should have never turned down money for the Medicaid expansion and this will make matters worse.      Peter Donofrio  Kathleen Donofrio  1708 Linden Avenue  Nashville, Tn 37212  18 Jonathan Reeve From: Sent: To: Subject: rorlowske@everyactioncustom.com on behalf of Veronica Bourassa Friday, October 18, 2019 6:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Veronica Bourassa  8429 Back Valley Rd  Evensville, TN 37332‐3269 rorlowske@gmail.com  19 Jonathan Reeve From: Sent: To: Subject: kdunn2005@comcast.net Friday, October 18, 2019 5:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] comments regarding the Block Grant/Gov Lee is proposing   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   These comments are for the use as Public Notice comments on the Block Grant  for healthcare as proposed by Gov. Lee.    I am lived in Nashville almost all my 74 yrs and have always been very proud to  share with friends that TN is the ‘health care capital of the World”! Now, I am re‐ thinking that opinion and would ask you all to consider my comments.   1. TN leads the country in hospital closings since we have refused to expand  Medicaid. This is information from our own Sen. Frist’s Sycamore Institute  index.  2. Cancer treatments: This is very personal to me because I have had colon  cancer and was treated at Vanderbilt Univ Oncology dept, with an excellent  staff. However, I was lucky because I have good insurance and can pay for  it! But, I have been shocked to learn that cancer deaths are climbing in TN,  unlike any other state in the county. This should not be happening!  3. TN children are suffering, especially the most vulnerable. And, as well, the  health of mothers from maternal deaths rising is unacceptable.   4. The State was offered approx. 1 billion $$$ in health assistance from the  Federal Government…why have we not taken it? Your responsibility/our  responsibility is to take care of our people, especially the most vulnerable.  And we had the ability to do so and turned our backs on it!!  5. Gov Haslam supported the expansion of TennCare…but look what has  happened!    I SUPPORT THE EXPANSION OF MEDICAID AND NOT PASSING THE BLOCK  GRANT IDEA AS OUR HEALTHCARE OPTION. IT IS SHORT SIGHTED AND  AGAISNT THE SPIRIT OF OUR COUNTRY AND OUR CITIZENS.  Karen Cochran  20 114 Prospect Hill  Nashville, TN 37205    21 Jonathan Reeve From: Sent: To: Subject: Denise Ondrejcak Friday, October 18, 2019 5:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  How many public opinions were received? What was the breakdown—for and against? Thanks! Denise Ondrejcak    Sent from my iPhone  22 Jonathan Reeve From: Sent: To: Subject: jeanne40@everyactioncustom.com on behalf of Jeanne Guidi Friday, October 18, 2019 9:29 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Stop this bone-headed Block Grant Scheme!     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am strongly opposed to the Amendment 42 AKA Bill Lee's "block grant" scheme.  This proposal will do nothing to  correct or improve the horrific healthcare record that has been the history of TennCare.  With little or no oversight, why  should anyone turn over billions of dollars over to a state that expelled 200,000 children from the TennCare rolls and is  already at or near the bottom of every healthcare measure?  There is NOTHING in the block grant proposal that speaks  to IMPROVING healthcare outcomes.  It is all about avoiding Federal oversight and hiding any money saved.  When TN is  already at the bottom of expenditures per patient, it is ludicrous to assume that money can be skimmed out of the  already minimal public healthcare system and improve patient care.  This scheme will lead to less access to healthcare  and worse outcomes.      The fact is that this block grant scheme does NOTHING to expand healthcare to the more than 300,000 in TN who have  no healthcare.  This will do nothing to alleviate the healthcare crisis in rural areas where 13 hospitals have already closed  and another 20 are in danger of closing due to the lack of health insurance of our citizens and the economic distress of  so many of our counties.  And why would any company move into those communities when there are no hospitals to  service their employees?  Why would any more retirees move to our beautiful state when they cannot reach a hospital  within a reasonable amount of time?    The Republican majority's refusal to expand Medicare is absolutely criminal.  There no excuse for such bone‐headed  policy which has damaged our economy, debilitated our state's healthcare infrastructure, cut jobs, and put the well‐ being of our citizens at risk.  The Republican refusal to expand Medicaid is a direct cause of our rural hospital crisis.  72%  of all rural hospital closures since 2010 have occurred in states that refused to expand Medicaid.  TN has the highest  rural hospital closure rate per capital.  You think that is just a coincidence?  Do you think it is a coincidence that Ohio has  a 96% treatment rate for opioid addiction while TN's treatment rate is only 11%?  Ohio expanded Medicaid.  TN did not.     Why would you allow our healthcare infrastructure, which is key to attracting economic development and new  residents, to decay to the point where we have life threatening healthcare deserts?  The refusal to accept Medicaid  dollars (which we are already paying for!!!!) if fiscal malfeasance.  We have turned away billions of dollars that would  have gone to improve healthcare in our state and keep hospitals open and jobs in our communities.  We have counties  where the only healthcare available is the back of an ambulance which can take up to an hour to arrive and another  hour to get to a hospital.  Good luck if you have a heart attack or you are bleeding to death!    There is no wonder that the only people who want this proposed block grant scheme are Bill Lee and the bone‐headed  "leadership" in the state legislature who refused Medicaid expansion based on pure racism.  It is time for the State of TN  to do the right thing for its citizens and accept Medicaid expansion.      This block grant scheme is simply a bait and switch.  There is no upside for the State of TN in turning TennCare into a  block grant scheme.  Stop the non‐sense.  Step up to the job of taking care of our citizens and our healthcare  infrastructure.  Refusal to expand Medicaid is simply adding to the economic distress of our rural communities.        23 Jeanne Rosetta Guidi  Jackson, TN      Sincerely,  Ms. Jeanne Guidi  125 Hurts Chapel Rd  Jackson, TN 38301‐8647 jeanne40@hotmail.com  24 Jonathan Reeve From: Sent: To: Subject: ecanahuati@everyactioncustom.com on behalf of Emilia Canahuati Friday, October 18, 2019 5:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Emilia Canahuati  1510 Grandview Dr  Nashville, TN 37215‐3032 ecanahuati@gmail.com  25 Jonathan Reeve From: Sent: To: Subject: Laura Payne Friday, October 18, 2019 5:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] public comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you for the opportunity to make public comments. The block grants will much less for many more people in TN.   26 Jonathan Reeve From: Sent: To: Subject: cruzecon@everyactioncustom.com on behalf of Ethan Cruze Friday, October 18, 2019 5:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans‐ ESPECIALLY children and those with rare conditions.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ethan Cruze  Bean Station, TN 37708  cruzecon@aol.com  27 Jonathan Reeve From: Sent: To: Subject: Sandy Vredeveld Friday, October 18, 2019 4:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 Dear Director Roberts, I am submitting the following comments regarding the proposed Amendment 42 to convert federal funding for TennCare into a block grant. I am a retired hospital pharmacist with more than 34 years in health care, and I have been active in the Chattanooga community in assisting the underserved. I have witnessed firsthand the challenges of this population. As you know, the Tennessee population is one of the sickest in the country, with estimates that approximately 675,000 have no health insurance. I find it disturbing that TN politicians have continued to deny the expansion of Medicaid for the neediest of Tennesseans. There is considerable evidence that residents of states that have expanded Medicaid have improved health care. Lack of health care impacts human lives in ways not limited to clinical care. I would like state efforts to be focused on improving the health care of Tennessee residents, and I believe Amendment 42 would have detrimental effects on our most vulnerable population. While the actual amendment doesn’t promise savings, Governor Lee has made empty political promises of substantial savings. However, any savings would have to come at the expense of decreasing enrollees, cutting services, or cutting reimbursement to providers. The amendment states that there are operational efficiencies that can be improved. Amendment 42 is the cliched “throwing the baby out with the bathwater”. TennCare saves lives and improves dignity of our residents. Improvements can be implemented without a complete redesign. There are also several specific points in the amendment that concern me: 1. Enrollment numbers. Using 2016, 2017 and 2018 average member months will underestimate the eligible individuals. There were several situations that caused members to be disenrolled during this period. 2. Lack of federal oversight. Federal protections are the lowest level of protection for citizens. We only need to look as far as the politically based decisions that Tennessee 28 representatives made which were detrimental to TN residents, but served their political party’s needs. There must be checks and balances, assuring compliance with provision of health services. 3. Benefit changes. The amendment allows changes to benefit packages without CMS approval. CMS oversight prevents TN from removing basic services, especially those that are politically motivated. 4. Exemption from new mandates. Federal mandates offer protections that are in the best interest of all US citizens. Allowing exemptions would give TN the freedom to avoid adopting a critical component that is required in every other state. Why should the most basic services be denied in TN? We don’t know what future mandates are needed to protect the healthcare of citizens, but TN should not be allowed to be exempt from future protections. Amendment 42 appears to be a $7.9 Billion experiment. It is disturbing to me that this amendment was produced in a vacuum without consultation with the health care providers and organizations in Tennessee, and that only four public comment periods were completed in a short time. Amendment 42 is a serious step backwards, and I believe that it will have a severe negative impact on Tennessee’s most vulnerable population. Sincerely, Sandy Vredeveld, D.Ph. ssv113@outlook.com  (423) 326-5651     29 Jonathan Reeve From: Sent: To: Subject: Shiro Onedera Friday, October 18, 2019 4:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] For Public Comment - Tennessee Medicaid Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***     As a proud Tennessean, I'd like to start my public comment by quoting another Tennessean who was probably the best  President of the United States to come from our beloved State.    "Well may the boldest fear and the wisest tremble when incurring responsibilities on which may depend our country's peace and prosperity, and in some degree the hopes and happiness of the whole human family."   ‐  President James K. Polk    When I think of the opportunity we have to build a HEALTHIER Tennessee, I have the hardest time believing that this  Medicaid Block Grant Proposal would be the answer that my fellow Tennesseans deserve, most especially the poor and  those that are in the "Katie Beckett Population".  This is a tragedy and reflects badly upon Tennessee.    When reviewing the proposal, I see substantial verbiage and emphasis being placed on shared savings. I feel the  emphasis should be on these types of savings instead: saving lives, saving families, saving jobs, and saving our State from  a horrible decision. Is anyone taking a reading of the moral pulse of this proposal?  Is this being driven by human  compassion or the billfolds of ideological interests?    Shrinking Medicaid from its current levels is just wrong and it is the poor who will suffer the most. Who speaks for  them?  Have our hearts turned so dark that our senses fail to recognize the pain others are experiencing?    With regards to the "Katie Beckett Population," the wording in this proposal is so vague. This leaves so many individuals  with disabilities in limbo and facing an exhaustive path to realizing a better life.  Will this proposal do enough for them?    Transparency seems to have been an afterthought in this proposal. When trying to understand what this proposal hopes  to accomplish, I get this horrible gut feeling that medical fraud is not balanced to look at payee and payor in an equal  fashion. What a shame.    In closing, I would like to quote another great Tennessean who, in his own words, says it pretty well:    " Our state should focus on getting everyone in Tennessee health insurance coverage instead of unleashing managed  care organizations to squeeze savings from the poor." ‐ Congressman Jim Cooper, TN‐5th    Advocating for the poor and the vulnerable takes courage.  Let's find a better way for Tennessee... together!    I hereby submit this for public comment.    Sincerely,    Shiro Onedera  Old Hickory, TN  30   ‐‐   Sincerely,  Shiro Onedera CHIEF DATA ARTISAN / PRESIDENT PH: (615) 829-2811 EM: SHIRO@SERAPHIMANALYTICS.COM WS: WWW.SERAPHIMANALYTICS.COM To help protect y ou r priv acy , Microsoft Office prev ented automatic download of this picture from the Internet. NOTICE: This email message is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message. 31 Jonathan Reeve From: Sent: To: Cc: Subject: bradleyadler@aol.com Friday, October 18, 2019 4:54 PM PUBLICE NOTICE TENNCARE bradleyadler@aol.com; omadunk@bellsouth.net [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Sir, I have to oppose the block grand option. You have heard the old American proverb, "The squeaky wheel gets the grease." My son and thousands of Tennesseeans like him are NOT squeaky wheels. They are dealing with illnesses like schizoaffective disorder, bipolar disorder and other similar mood or thought disorders and usually go through life just getting by, unable to be part of the work force. The are gentle, quiet, respectful and I have learned to measure them, not by how great they have become, but rather by what they have overcome to be where they are in life. You must understand they are the forgotten ones, those who are NOT squeaky wheels. I'm afraid when it comes time to measure out the monies in question, they will dwell in the cellar of the budget...I wish it were not the case. Respectfully. Bradley Adler Hendersonville, Tenn 37075 32 Jonathan Reeve From: Sent: To: Subject: Connor Mcpherson Friday, October 18, 2019 4:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose Governor Lee's proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Greetings!        My name is Connor McPherson. I am a resident of Chattanooga and have been all my life. I have read the news about  Governor Lee's proposed bill, and I find it startling, if not unrealistic. It is silly to believe the state could save $1 billion  while somehow retaining the level of care it does to vulnerable families. Programs like healthcare and welfare are meant  to close the class gap, not widen it, and giving the state more money at the expense of its citizens is a sure way to  alienate our most vulnerable citizens. If we're not using our resources to support the people who need it, who are we  benefiting instead?        I oppose Governor Lee's proposal. Thank you for your time.    Blessings,          Connor McPherson  33 Jonathan Reeve From: Sent: To: Subject: Jessica Hejny Friday, October 18, 2019 4:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment on Demonstration Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare Administrators,     I am writing to expression my concern about the proposal to transition state Medicaid funding to a modified block grant.  Not only would this change be unprecedented in the history of Medicaid administration, but the change also opens up  the possibility that Medicaid care could be provided to fewer Tennesseans. Specifically, I am concerned about the lifting  of federal rules regarding the amount, duration, and scope of Medicaid services. These rules concerning which  populations must be covered and what services must be provided exist to ensure that all Medicaid clients nationwide  receive a base standard of care. Concomitant with the block grant, Tennessee is asking that these federal rules be  relaxed. I believe this opens the window for Tennessee to cover fewer people and services. Though the state asserts that  they do not intend to cover fewer people and services, there will be nothing stopping the state from doing so in the  name of cost efficiency. This is a dangerous move. Regarding the block grant, the fact that it is 'modified' removes the  traditional concerns with running out of funding. However, I am concerned that, if approved by the Trump  Administration, this would set a new standard for Medicaid funding that would upend the way Medicaid has been  funded since its inception. I believe the existing Medicaid funding structure in which states are more constrained in how  they spend Medicaid dollars and are more strictly governed by federal rules regarding who and what is covered should  remain in place. This model works and has worked for over 50 years. If Tennessee wishes to cover more populations in  order to support the health of its citizens, it can choose to do so of its own volition. A start would be to expand Medicaid  to cover a larger portion of low income Tennesseans. The fact that the state has chosen not to expand Medicaid gives  reason to be skeptical of the impulse behind the request to shift Medicaid funding to a modified block grant model. In  short, show us that you are driven primarily by the health needs of citizens of the state before you suggest dramatic  changes to existing health programs. In sum, I do not support the proposal to shift Tennessee's Medicaid funding to a  modified block grant (Demonstration Amendment 42).     Sincerely,   Jessica Hejny  34 Jonathan Reeve From: Sent: To: Subject: Tina Wells Davenport Friday, October 18, 2019 4:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Gabe Roberts, Director  Division of TennCare    Dear Mr. Roberts,     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, including people like my sister. My sister is intellectually and developmentally  disabled, and she relies on TennCare for vital health and behavioral services that enable her to live a happy and  productive life as a member of the Middle Tennessee community.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,    Tina Davenport  Murfreesboro, TN 37128  35 Jonathan Reeve From: Sent: To: Subject: Gregg Shepard Friday, October 18, 2019 4:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] opposed to the medicaide block grant.   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am a resident of Nashville in Davidson County.  I am also a practicing medical doctor specializing in both internal  medicine and Oncology.  This involves cancer and blood disorder treatment.  This involves treatment of a wide spectrum  of individuals from all parts of our society and I strive to provide the best possible medical care regardless of social,  economic, gender race or other factors.  In my review of the wording in the application for the Medicare block Grant I  am concerned that this requests exemption from oversight and it allows the state to determine coverage at different  levels for different types of individuals.  I am concerned that this block Grant will have unintended consequences  resulting in negative outcomes for patients with cancer particularly for vulnerable populations.  Please consider  withdrawing the request for a block Grant and instead pursuing medicate expansion as many other states have  pursued.  This would provide most of the goals of the block Grant including increased Federal funding and expanded  coverage.  If that is not possible then please consider making sure that any health plan devised by the State of  Tennessee provides coverage on equivalent level as that provided under Federal regulations and other situations.    Gregg Shepard.  MD  Nashville,  TN.  This email message and any attachments are for the sole use of the intended recipient(s) and may contain  CONFIDENTIAL and/or PRIVILEGED information. Any unauthorized review, use, disclosure or distribution is prohibited. If  you are not the intended recipient, please notify the sender and destroy all copies of the original message and any  attachments.   36 Jonathan Reeve From: Sent: To: Cc: Subject: Sergio Ricardo Pacheco Cruz Friday, October 18, 2019 4:09 PM PUBLICE NOTICE TENNCARE Jessica Hejny [EXTERNAL] Comment on Demonstration Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   On January 1, 1994, TennCare replaced the Medicaid program in Tennessee providing service to Medicaid eligible individuals, uninsured people who lacked access to insurance, and uninsured people who were turned down for health insurance due to a health condition. TennCare’s new proposal, a block grant, emphasizes on state accountability. TennCare states that it operates one of the most cost-effective Medicaid programs in the nation, according to the Division of TennCare. I agree with the proposal because of the fact that with Medicaid, some states were said to overspend, while other states that tried to control their spending received reductions in federal funding. The block grant proposal makes it possible for the federal government to make a contribution to the state, despite the number of applicants in the program. Governor Bill Lee said the new proposal would not change the quality of Medicaid services, but actually lower the cost, according to the Washington Post. President Trump has shown support toward the block grant idea but has not been approved by his administration. Republicans in Congress have been trying to get rid of former president Barack Obama’s Affordable Care Act, so the block grant will most likely be approved, according to the Pew Charitable Trust. The proposal is said to be calculated on the average TennCare enrollment during State Fiscal Years 2016, 2017, and 2018. It will then be multiplied by the federal government’s projections of what the Medicaid cost be in the state of Tennessee. The block grant also proposes that in any year in which the state underspends, the state will keep 50% of the federal share of the savings. The proposal is said to provide flexibilities that will create improvements, provide efficiencies, and other reforms to make TennCare more effective. The proposal also stated that the block grant amount will be adjusted every year, which will help with the rising cost of health care, according to the Division of TennCare    37 Jonathan Reeve From: Sent: To: Subject: Elizabeth McCachren Friday, October 18, 2019 4:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grants     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  My husband and I are fortunate to have a good income and good health insurance.  My heart hurts for those who are  dependent on the state of Tennessee to help them get health care.  The state should understand that a healthy child is  more likely to grow up to be a self‐supporting, contributing member of society.  And if their parents and grandparents  also have health care, they can focus better on raising good citizens.  It therefore benefits TN to spend money on health  care for its poorest citizens, NOT look for ways to save money!    I am firmly opposed to the block grant proposal.  Everything I read makes me more fervently wish TN had expanded  Medicaid.  Please reconsider and expand Medicaid!    Sincerely    Elizabeth T. McCachren  1109 Oxford Hills Drive  Maryville, TN  37803  38 Jonathan Reeve From: Sent: To: Cc: Subject: Miller, Holly Elizabeth Friday, October 18, 2019 4:02 PM PUBLICE NOTICE TENNCARE Miller, Holly Elizabeth [EXTERNAL] TN Medicaid Block Grant Proposal Comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr Roberts, I am writing in opposition to Amendment 42, the proposal to change the funding mechanism of TN Medicaid (aka TennCare) to a block grant. I am a pediatric primary care nurse practitioner, and I have been practicing in Nashville, TN for 11 years. Our clinic cares for underserved and at risk children - children from low SES households, with complicated social stressors, inadequate access to resources for health maintenance and illness prevention, and often complex chronic medical conditions. Over 90% of our over 15,000 patients receive insurance coverage through TennCare. In general, over half of TennCare recipients are children and, because TN did not expand Medicaid through the ACA, all recipients are from vulnerable population groups. Comprehensive, reliable medical benefits are a must for these at risk populations. These populations should not be used as guinea pigs for a state seeking freedom from Federal oversight through an experimental waiver. There are several specific concerns I have with the proposal that I feel could cause harm to my patients: Our clinic has seen a notable increase recently in children being dropped from TennCare coverage when they are in fact eligible for continued benefits. Despite several meetings with TennCare about this, the reason why this is happening is still unclear. But data has shown that about 100,000 TN kids have lost coverage over the last 2 years. If enrollment data from 2016-2018 is used to calculate the block grant amount, it will likely underestimate the cost needed to cover these dropped patients when they become re-enrolled. The block grant calculation also does not account for an increase in cost of care for enrollees if increased health expenditures were needed during a future crisis, say for example, during a sudden measles outbreak. Another concern is related to potential changes to the drug formulary. The proposal states the formulary would be closed with as few as one covered drug per therapeutic class. The ability to pick the best drug for each patient would be severely limited, as would the availability of off-label drugs. Off-label prescribing is avoided when possible but is very common in pediatrics, as about half of all drugs have no FDA approved label use in children. In addition, there is no process to ensure that the full scope of Early and Periodic Screening, Diagnostic, and Treatment program benefits (EPSDT) will be protected. If needed, to save money, TennCare could decide that routine developmental screening questionnaires, preventive care bloodwork, or vaccinations at certain ages are no longer covered. The proposal must guarantee that EPSDT benefits will be protected. While the proposal states there will be no cut in eligible/covered populations nor benefits offered, there is no mechanism in place to ensure this will in fact be honored. There is no plan for oversight, no accountability. When the rubber meets the road and the block grant funds run out, we could see cuts in either eligibility, benefits, or both, and none of these options are acceptable. TennCare stakeholders should be able to offer comments or concerns regarding future program changes, since those on the ground can offer the best insight as to how proposed changes will impact enrollees and their families. Thank you for your consideration of these concerns.   Sincerely,  Holly Miller, MSN, APRN, CPNP-BC holly.miller@vumc.org 40 Jonathan Reeve From: Sent: To: Subject: Sandra Friday, October 18, 2019 3:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TN Care     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐    It is needed ‐ not a water down plan  Sandra V Moore  Health Care Professional   Sent from my iPhone  41 Jonathan Reeve From: Sent: To: Subject: henrietta hagler Friday, October 18, 2019 3:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Please, no!   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I urge you to read Tennessee Congressman Jim Cooper’s statement and act accordingly!  Henrietta Hagler   Hendersonville 37075  42 Jonathan Reeve From: Sent: To: Subject: dacabutler@everyactioncustom.com on behalf of David And Carol Butler Friday, October 18, 2019 3:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. David And Carol Butler  35 Asbury Ln  Hermitage, TN 37076‐2166  dacabutler@gmail.com  43 Jonathan Reeve From: Sent: To: Subject: william.haynes@everyactioncustom.com on behalf of William Haynes Friday, October 18, 2019 3:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. William Haynes  1124 Timbergrove Dr  Knoxville, TN 37919‐8445 william.haynes@usa.net  44 Jonathan Reeve From: Sent: To: Subject: ammediala@aol.com Friday, October 18, 2019 3:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I think these block grants are dangerous to the population who need medical care the most. I do not think the people of TN deserve to be part of an 'experiment' that no other state chooses to participate in for a reason. I believe this is careless and a prime example of politicians playing fast and loose with the people on TN and their lives. Furthermore, it does nothing to address the more than half million Tennesseans who have no health insurance to begin with. It is shameful for the people to be treated this way, and this should NOT happen. What a horrible choice. Leslie Selfe 10597 Rockvale Rd Rockvale, TN 37153 45 Jonathan Reeve From: Sent: To: Subject: bj.snell@everyactioncustom.com on behalf of Barbara Snell Friday, October 18, 2019 2:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     PLEASE remember the people this is supposed to help. Services should NOT be CUT!!    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  ms Barbara Snell  910 Belvedere Dr  Gallatin, TN 37066‐3406 bj.snell@comcast.net  46 Jonathan Reeve From: Sent: To: Subject: Joyce Friday, October 18, 2019 2:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposed to Block Grant Funding of Medicare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am opposed to block grant funding of Medicare. I believe this model will result in less medical coverage for people who need it. I believe the primary goal of this model is to save the state of Tennessee money. It's clear that Governor Lee is misinformed about this issue. The best way to offer adequate medical care to those who need it in Tennessee is to expand Medicaid, just as 36 other states have done. Joyce L. Feld  1540 Agawela Ave  Knoxville, TN 37919  865-525-4007  47 Jonathan Reeve From: Sent: To: Subject: Shawn Lee Friday, October 18, 2019 2:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I vigorously oppose the block grant proposal.   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I live in Nashville Tennessee and work in the healthcare community.  I am strongly opposed to the block grant proposal.    Shawn Lee  4176 Creek Trail Dr, Whites Creek, TN 37189    48 Jonathan Reeve From: Sent: To: Cc: Subject: Nicole Wellford Friday, October 18, 2019 2:48 PM PUBLICE NOTICE TENNCARE sen.brian.kelsey@capitol.tn.gov [EXTERNAL] Opposition to Medicaid Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Roberts,  I strongly oppose Tennessee’s Medicaid block grant proposal. Its effects will be to the detriment of Tennesseans,  especially those for whom Medicaid was created‐ children, pregnant women and caretakers or relatives of minor  children, the elderly, and other people with disabilities.   I read the Notice of Change in TennCare Demonstration: Amendment 42 (Block Grant), the draft version, the  executive summary, the overview and the frequently asked questions. The materials provided lack specifics to the point  it is disturbingly vague and merits the concern of Tennesseans.   The proposal attempts to use ambiguities for the purpose of flexibility with TennCare and to escape some  federal oversight. I can understand not necessarily wanting all the oversight and that it could be considered  cumbersome. However, with this extra freedom comes the risk that the funding might be misused and it is troublesome  when our state has some of the highest maternal and infant mortality rates and a low life expectancy. Due to a myriad  of problems, 200,000 children in the state within the past two years were cut off from TennCare in spite of some who  remained eligible and some seniors were adversely affected when TennCare erred in removing money from their Social  Security checks. I recognize there is an effort to also crack down on any fraud that would be assisted with the block  grant, but the only article I could find was in the Atlanta Journal‐Constitution about Georgians abusing our system;  surely other methods could be used to remove such individuals from TennCare.  The block grant indicates the prices of medications could be negotiated, which is an asset. Nevertheless, we  could already be negotiating prices without this grant and should commence doing such before the proposal takes  effect, presuming it will be approved by the federal government. I find it problematic that this proposal excludes  calculations for prescription drugs and hospital payments for uncompensated care. Even with negotiations, costs of  medications continue to increase and I worry about people who are on TennCare could face more adversity by leaving  out the calculations for drugs. To boot, I did not see in any documents anything that would truly assist hospitals from  facing closure.  Tennesseans will be the “guinea pigs” of the country if the government approves this modified block grant  proposal, and it comes at a time when our state ranks first in people who file for medical bankruptcy. The amount of  people with health insurance continues to decrease and affordable access to healthcare is so poor that it became legal  on July 1, 2018 for physicians to barter with patients in lieu of monetary payment. That the state legislature and then‐ Governor Haslam recognized the alarming hardships should have served as a red flag that Tennesseans need immediate  help and an expansion of TennCare.   Based on an article I read from the Knoxville News Sentinel, there was one person in Chattanooga who voiced  his or her support for the modified block grant proposal. Every other person at all other public hearings on the issue  were against the proposal or at least voiced serious reservations about it. That means 139 of 140 people, or about  99.28% of speakers were against it. Governor Lee dismissed comments by Tennesseans who spoke out against the block  49 grant by saying we are “misinformed or have not really taken the time to really understand it.” What the governor said  could be true in some cases, though it certainly does not apply to every single individual who gave his or her or their  input at the public hearings. Governor Lee is trying to blame Tennesseans for not liking this faulty TennCare grant  proposal as if we are failing the state by not supporting this block grant when in fact the state government, the governor  himself, and the state legislators who are in favor of it are failing us Tennesseans.  Since a proposal must be submitted and based on the feedback from the public hearings, I think a provision  should be included that would absolutely cause the government to reject the modified block grant proposal and allow  the state to either prepare a more concrete proposal or to reassess going forth with any form of a block grant.  Tennesseans are dying without access to affordable care or are inundated with insurmountable debt as a result of a lack  of insurance coverage when they do not qualify for TennCare or cannot afford the cost of a plan through the Affordable  Care Act. The proposal does not go far enough in assuring Tennesseans that any relief may come by expanding the  number of recipients on TennCare and it does not rule out the decrease in coverage of services to current TennCare  members.   I encourage you to share Tennesseans’ thoughts with the state legislature so they will consider the input of all  Tennesseans for future votes on healthcare‐related matters.   Sincerely,  Alexandria Wellford     50 Jonathan Reeve From: Sent: To: Cc: Subject: Russell Overby Friday, October 18, 2019 2:45 PM Allison Jones; PUBLICE NOTICE TENNCARE Shelby Dodson [EXTERNAL] RE: Legal Aid Society Comments to Proposed Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thanks Allison and Shelby for your great work.    RUSSELL OVERBY   Attorney roverby@las.org Direct:  (615) 780‐7109 Toll Free:  (800) 238‐1443 Fax:  (615) 244‐4920 1321 Murfreesboro Pike  Suite 400  Nashville,  TN   37217   www.las.org              Confidentiality Notice: The foregoing message and all attachments transmitted with it may contain  legally privileged and confidential information intended solely for the use of the individual or entity to whom it is addressed. Privileges are not waived by virtue of this having been sent by electronic transmission. If the reader of this message is not the intended recipient, you are hereby notified that  forwarding,  communicating,  disseminating,  distributing,  copying,  or  otherwise  using  this message or its attachments is strictly prohibited. If you believe you have received this transmission  in error, please notify the sender immediately and delete the information without retaining any copies. Thank you.      From: Allison Jones   Sent: Friday, October 18, 2019 2:09 PM  To: public.notice.tenncare@tn.gov  Cc: Russell Overby ; Shelby Dodson   Subject: Legal Aid Society Comments to Proposed Amendment 42    Good afternoon.    Please find attached comments submitted by the Legal Aid Society of Middle Tennessee on behalf of our clients and the  communities we serve.    Thank you for the opportunity to comment on the proposed rule changes.    Sincerely,  Allison Jones  ALLISON JONES Attorney 51 ajones@las.org 1321 Murfreesboro Pike  Suite 400  Nashville,  TN   37217 Direct:  (615) 780‐7105 Toll Free:  (800) 238‐1443 Fax:  (615) 244‐4920     www.las.org      Confidentiality Notice: The foregoing message and all attachments transmitted with it may contain legally privileged and confidential information intended solely for the use of the individual or entity  to whom it is addressed. Privileges are not waived by virtue of this having been sent by electronic transmission. If the reader of this message is not the intended recipient, you are hereby notified that  forwarding,  communicating,  disseminating,  distributing,  copying,  or  otherwise  using  this message or its attachments is strictly prohibited. If you believe you have received this transmission in error, please notify the sender immediately and delete the information without retaining any copies. Thank you.      52 Jonathan Reeve From: Sent: To: Subject: charlie harris Friday, October 18, 2019 2:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To whom it may concern,     I vehemently oppose the Block Grant Proposal being pitched by our governor and his fellow TN GOP members.  Healthcare coverage in Tennessee is woefully inadequate. Rural hospitals have been closing for years and Tennesseans  that have no insurance or few options are suffering. And, rather than expanding Medicaid, ensuring coverage for many  citizens of this state, our State's leadership is hell‐bent on this experimental, unprecedented block grant program ‐‐ just  so they can pound their chests and say they did something differently and didn't take Federal money in previous years  (which again led to Tennesseans suffering and dying without medical coverage).     It's time for leadership in this state to provide adequate healthcare to its citizens and stop fooling around with  experimental programs (that very well could be rejected). Show some backbone and prove that you value people over  party ‐‐ there are so many people that need help covering medical costs. It's time to think about them and not stubborn  adherence to the "small government and states rights" mantra that has led to the healthcare emergency we have in this  state now.     Thank you for your time. Do what's best for people, not conservative credibility.     Charlie Harris, Davidson County resident and Tennessean my whole life. (37206)     53 Jonathan Reeve From: Sent: To: Subject: Payton Robbins Friday, October 18, 2019 2:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TN Medical Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Decision Makers,    The Medical Block Grant proposal is a dangerous experiment that threatens health coverage for thousands of  Tennesseans.     We need Medicaid expansion now to save rural hospitals. The county where I grew up and my parents still live has no  hospital for the first time in my lifetime. It recently closed. Neighboring county hospitals are also closed or are closing.     Please do your duty and expand Medicaid now instead of “experimenting” with the health of Tennesseans like my  parents.     Sincerely,    Payton. C. Robbins  6084 Hagars Grove Pass   Hermitage, TN 37076  Landowner, Taxpayer and Voter       Sent from my iPhone  54 Jonathan Reeve From: Sent: To: Subject: Ann Indingaro Friday, October 18, 2019 2:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Feedback on Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Friday, Oct. 18, 2019     To Whom it May Concern:     Please count me among those opposing Gov. Lee’s block grant proposal for TennCare funding.  My reasons  include:  1)  TennCare has been severely underfunded for years.  Every federal dollar we can get needs to go  towards providing healthcare for Tennessee residents.  No money should be diverted toward  administrative costs, or worse, for other non‐healthcare related expenditures.  A block grant could  easily turn into a big slush fund with inadequate supervision.     2) TennCare has been severely underfunded for years. Thus many residents have found themselves  ineligible for coverage, and/or their coverage curtailed, and/or their providers, treatments and  prescriptions severely limited.  Medicaid will pay for claims for thousands of additional residents, while  TennCare will need to overhaul its policies and procedures to come into compliance.  Is that why we  need a block grant?     3)  TennCare has been severely underfunded for years.  Many rural—and other—hospitals in  Tennessee have had to close as their clientele has been decimated.  Medicaid will pay for claims  restoring this clientele. But Medicaid cannot re‐open hospitals.  A block grant would be a tempting  honey pot.     4) The state of Tennessee has been running and underfunding TennCare.  It has botched the job.  How  can we trust state officials to spend federal money wisely?  “Getting rid of red tape” is code for  “assuring freedom from accountability.”     5) Not to mention:  How can there be a cap on the block grant, and at the same time a guarantee that  it will increase as more people submit more (and more expensive) claims? This is wishful thinking and  poor mathematical reasoning.     Margaret Ann Indingaro  4666 Marcel Ave.  Memphis, TN  38122  55 Jonathan Reeve From: Sent: To: Subject: schlacter9@everyactioncustom.com on behalf of Michael Schlacter Friday, October 18, 2019 1:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Additionally How can there be any integrity in Tennessee developing a new program and spend less money when  Tennessee has failed to provide hospitals and care for all Tennesseans to date with TennCare.  This would be another  attack on the aged and poor and defenseless persons of Tennessee.     Sincerely,  Mr. Michael Schlacter  6037 Brentwood Chase Dr  Brentwood, TN 37027‐4449 schlacter9@gmail.com  56 Jonathan Reeve From: Sent: To: Subject: aefrey03@everyactioncustom.com on behalf of Adrienne Frey Friday, October 18, 2019 1:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Adrienne Frey  403 Stable Dr  Franklin, TN 37069‐4138  aefrey03@gmail.com  57 Jonathan Reeve From: Sent: To: Subject: alan@rossmusic.net Friday, October 18, 2019 1:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Stop the block grant!   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, TennCare is important to my stepson, providing him with comprehensive health care coverage he so desperately needs. He is diagnosed paranoid schizophrenic and relies on TennCare for crucial health treatments and to manage his condition. TennCare has helped him greatly over the past 14 years. I am concerned about the plan to change TennCare into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly our citizens with mental illness. This proposal potentially would allow the state to eliminate or restrict services important to people with mental illness. More people need access to TennCare, not less! I respectfully urge you to reconsider this proposal and focus on solutions that truly aid Tennesseans with mental illness. Sincerely, Alan Ross 58 Jonathan Reeve From: Sent: To: Subject: Lynn Fritz Friday, October 18, 2019 1:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment on proposed TennCare Medicaid block grant waiver   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, As a Legislative Advocacy Volunteer for NAMI Davidson County, I am very concerned about the plan to convert the TennCare Medicaid program to a “block grant,” for a number of reasons: Tennessee currently ranks poorly in many measures of health care. Note the following statistics: - Tennessee’s health care ranked #43 in the nation in 2018. (source: U.S News & World Report) - Tennessee’s rate of uninsured residents rose by .6 percent in 2018, representing about 46,000 more Tennesseans without health insurance (Tennessean article, September 11, 2019) and tying for the third-largest rate increase nationwide as one of only 9 states to see their uninsured rate grow in 2018. (source: U.S. Census Bureau report, September 2019). According to the Census Bureau cited in the Tennessean article of September 11, “The Census Bureau now estimates that more than 675,000 Tennesseans – or about one in 10 state residents – have no insurance coverage.” - At the same time as our rate of uninsured residents increased, the proportion of people living under the federal poverty line increased from an estimated 15 percent in 2017 to 15.3 percent in 2018. (source: U.S. Census Bureau report, September 2019) When looking specifically at mental health, according to an analysis by Mental Health America quoted in a November 19, 2018 article in the Tennessean, Tennessee ranked 16thin the prevalence of mental illness but 46thin access to mental health care, and only one other state has a larger proportion of adults with mental illness who are uninsured. Tennesseans place great value on the importance of health care, with health care emerging as the top concern of voters in Vanderbilt University’s public policy poll in late 2018. This same poll also showed that 66% of registered voters in Tennessee favor Medicaid expansion. Our new governor, Bill Lee, has listed Mental Health among his top five funding priorities. Given the importance placed on health care by Tennessee residents and the poor state of our health care, now is the time to provide more resources for the health care of our most vulnerable citizens. The block grant proposal, however, seeks to extract $2 billion from Tennessee’s 59 Medicaid system to provide the state with $1 billion in funds to be used by the state in undefined ways, unrestricted by federal standards. To achieve these funds, the proposal suggests, for example, TennCare may only cover one drug in a class. For patients who are seeking to manage a serious mental illness, finding a drug that will effectively control and manage their illness and that will have tolerable side effects very often requires trying different medications and dosages and combinations. Covering only one drug will have seriously detrimental effects on the health of this vulnerable population. Ineffective treatment leads to destabilization of the individual’s mental health condition. The domino effect then leads to higher rates of crisis treatment service utilization, as noted by the Tennessee Department of Mental Health and Substance Abuse Services own Databook over the last 3 years. Savings are not realized. Also, these individuals are more likely to come in contact with the justice system. Concentrated efforts have been made for the last three years, across the state of Tennessee, by coalitions of providers, mental health advocates, law enforcement, justice and homeless representatives to divert people with mental health issues away from the justice system and into care. Limiting treatment options in a one-size-fits-all formulary is short-sighted, costly and inhumane. The block grant waiver proposal seeks to eliminate federal minimum standards and patient protections. Giving free rein to the state and its managed care contractors opens the door for corruption and abuse of the system. Unfortunately, Tennessee has already experienced corruption of this sort 20 years ago, and our state’s past shows the necessity of federal standards and safeguards. By removing the requirement for Tennesssee to follow the federal government’s list of optional and mandatory services, this proposal would allow for rationing of health care to save money. Given that patients needing mental health care have required parity laws to receive medical treatment equal to physical conditions, the possibility of state-determined cuts to services is a scary prospect indeed – whether these cuts come via elimination or restriction of services and levels of care, or limitations in drug choice or coverage or length of stay in care facilities, or via cuts in payments to providers. The block grant waiver proposal does not provide for a well-structured and defined appeals process for patients. At the same time that there is a possibility of patients’ health care being rationed, there is no system for patients to appeal coverage decisions or denials of services. A further suggested way of saving money is to institute copays for TennCare participants. This, along with forcing enrollees to pay the full cost of prescriptions that would no longer be covered will place a further financial burden on already vulnerable populations. In addition, as the state acknowledges, “TN operates one of the most cost-effective Medicaid programs in the nation.” This lean operation makes it apparent that achieving the desired further cost savings will require cuts in the amount of care a patient will receive. 60 TennCare has not shown that it has the systems and infrastructure to be entrusted with implementing a block grant. The past several years have included: significant problems with the rollout of their computerized TEDS system (incurring $400 million in cost overruns), the resulting difficulty of enrolling or renewing enrollment, and the inexplicable removal with no prior notice of upwards of 200,000 children, many of whom were still eligible for coverage. This track record indicates a lack of preparedness to be the first state to attempt a block grant program. Our residents, given the poor state of our health care, can ill afford being the subjects of this block grant experiment. I attended the block grant hearing in Nashville on October 1st. In a large full room of over 150 people, I listened as speaker after speaker spoke in opposition to this block grant proposal. Speakers opposed included Representative Jim Cooper, two pediatricians from the Tennessee chapter of the American Academy of Pediatrics, a nurse practitioner and clinic volunteer from rural Tennessee, a retired nurse practitioner who worked at the Department of Health and had witnessed the effects of the 2005-2008 period of TennCare disenrollment, the state director of the Tennessee Small Business Alliance, a legally blind senior TennCare enrollee, a representative of the Tennessee Primary Care Association of Community Health Centers, a family physician, NAMI Tennessee’s Executive Director as well as Advocacy Director, a Tennessee Justice Center and Tennessee Health Care Campaign volunteer, a pastor and father of an intellectually disabled son, the Director of Advocacy of the American Lung Association, the founder of TN Holler, a mom of a seriously ill daughter and TennCare enrollee, a social worker, an attorney with the Legal Aid Society of Middle Tennessee, the CEO of Mental Health America of Mid-South, a representative of AARP, a neuroscientist with a son with a rare brain disorder, a retired public health nurse, the Executive Director of the Tennessee Justice Center, a senior citizen who had lost her TennCare coverage due to problems with paperwork, a behavioral analyst who provides services for TennCare, and several citizens concerned about justice and various aspects of health care. Not one person in attendance, representating such a broad spectrum of health care stakeholders and interested cititzens, spoke in favor of the block grant. In comments after the hearing, Governor Bill Lee expressed that those who oppose the block grant fail to fully understand the complex proposal. The plan, however, is woefully lacking in detail. This lack of detail makes it impossible to support this plan. As the parent of an adult child who is living a very successful recovery with a serious mental illness, I know first-hand the importance of investing in quality treatment over a period of time. I know from our family’s experience that an investment in quality crisis care, in appropriate medications, in quality treatment for an appropriate period of time EARLY is exactly what is needed to promote health and prevent much greater costs in the future. Our daughter is now able to live independently, owns her own home, has a good job, and is a taxpaying contributor to our state. Without quality treatment, her positive outcome would not have happened, and our family would have incurred much greater health care costs over time, with the very real possibility of repeated crises and hospitalizations. Rather than looking to find ways to remove funds from TennCare, our state should be looking for ways to add funds. I can’t think 61 of a more worthy budget priority than investing in the long-term health of Tennesseans. Please reconsider this proposal and instead of looking to take money out of TennCare, look for ways to more fully fund health care in our state so that we can rise to the top in health care rankings, instead of bringing up the rear. Sincerely, Lynn Fritz NAMI Davidson County, Legislative Policy Volunteer  62 Jonathan Reeve From: Sent: To: Subject: BPAULSON@everyactioncustom.com on behalf of MERVIN PAULSON Friday, October 18, 2019 1:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I, and many others will not survive if you diminish coverage.  I'm having a hell of a time as it is @ age 80. I STRONGLY  OPPOSE BLOCK GRANTS! (((***AS YE DO UNTO OTHERS!***)))    Sincerely,  Mr. MERVIN PAULSON  365 Millwood Dr  Nashville, TN 37217‐1612 BPAULSON@AOL.COM  63 Jonathan Reeve From: Sent: To: Subject: Anthony Fox Friday, October 18, 2019 1:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposition to TennCare block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare, On behalf of the Tennessee Mental Health Consumers’ Association I’m am writing to share our opposition to a Medicaid Block grant program. Currently TennCare provides comprehensive health care coverage for people in need. TennCare is particularly important to adults with mental illness, many of whom rely on it to access essential health treatments (including a transportation benefit). We are concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. We are worried that this proposal would allow TennCare and Managed Care to eliminate or restrict services that are important to people we serve. More people need access to healthcare, not less. I urge you to reconsider this proposal. Our focus should be on helping Tennesseans with mental illness, not jeopardize their health and their recovery. Sincerely, Anthony Fox, CEO    Tennessee Mental Health Consumers’ Association   615 835 2223  afox@tmhca‐tn.org  www.tmhca‐tn.org  64 Jonathan Reeve From: Sent: To: Subject: baowens@everyactioncustom.com on behalf of Barbara Owens Friday, October 18, 2019 1:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Barbara Owens  300 Ridgetop Ct  Franklin, TN 37067‐4006 baowens@bellsouth.net  65 Jonathan Reeve From: Sent: To: Subject: Adelle Wood Friday, October 18, 2019 1:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on block grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the block grant proposal. It does not affect me or my family now, but it could in the future. It would greatly affect those who would be subject to it. It simply is not known and can't be known what the potential impact would be on medical effectiveness We need to expand TennCare eligibility so that Tennesseans who have limited resources can receive medical care, and the block grant program might not do so. I do not believe that the block grant amendment would reduce Tennessee's rate of those uninsured and it could well increase uncompensated care at hospitals, which has caused great hardships to those who need medical care and can no longer access it locally. The high rate of hospital closures in our state has also caused financial hardships to staff and surrounding businesses. I am strongly against Amendment 42 and urge that it be rejected. Sincerely, Adelle Wood 4641 Villa Green Drive Nashville, TN 37215 66 Jonathan Reeve From: Sent: To: Subject: fyly@everyactioncustom.com on behalf of Christine Scheinberg Friday, October 18, 2019 1:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     It would also fundamentally expose the Tennesse budget in times of recession when more people qualify under the  original criteria. or would force continual tinkering to reduce the covered population to match federal funding.  That in  turn, would harm needy Tennessee residents at the worst possible time.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Christine Scheinberg  Germantown, TN 38139  fyly@att.net  67 Jonathan Reeve From: Sent: To: Subject: rkersey@everyactioncustom.com on behalf of Roy Kersey Friday, October 18, 2019 12:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. There is a good reason no other state has done this. Economizing on health care  for the poor only shifts costs to the rest of the population as health care providers raise rates to compensate for "free"  care. Also, as health problems increase for the newly ineligible, the costs of "free" care for chronic and severe illnesses  will increase. There could be a tax saving to Tennesseans, but overall, citizen costs will rise and be borne by those least  able to tolerate the increased expenses...the working poor and lower middle class. emergency room waits and costs are  a chief complaint of the unlucky hit with an unexpected urgent or emergency health need.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Roy Kersey  637 Mize Cir  Seymour, TN 37865‐3313  rkersey@tds.net  68 Jonathan Reeve From: Sent: To: Subject: Margaret Moore Friday, October 18, 2019 1:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the TennCare Block proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the Tenncare Block proposal. It will not benefit anyone currently receiving services and will actually be a detriment to them/us. Don't hurt those who will be the most negatively affected by this. Margaret Moore Chattanooga, TN 37416 69 Jonathan Reeve From: Sent: To: Cc: Subject: Jerry O'Connor Friday, October 18, 2019 12:47 PM PUBLICE NOTICE TENNCARE jim.cooper@mail.house.gov [EXTERNAL] Block Grant Plan Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Ladies and Gentlemen: Scores of medical and health care professionals have told you what a horrible idea the block grants are and provided a great deal of evidence to back up their opinion. They have greater expertise than I, and greater expertise than the politicians who are touting this solution to Tennessee's health care crisis. I support their opinions. Hundreds of Tennessee citizens have testified about how they and their families could be adversely affected by the block grant plan and its implementation. I share their deep concerns. Exactly one hearing attendee was put in the “favoring”column, and his testimony was far from reassuring: "No one's ever done a block grant, so how can we sit here and say what is going to happen? We don't know." I can think of a lot of things that we could do just to see what might happen. But health care is literally life and death – it's certainly not something we should be experimenting with. Especially when we have an alternative that has worked for numerous other states – expanding Medicaid under the provisions of the Affordable Care Act. Let's be honest. The only reason that the Medicaid expansion option is not a top-of-list, slam dunk option is purely political. The Republicans who hold the super majority in the TN Legislature have demonized everything associated with former President Obama to curry favor with their supporters and national Republican leaders. And expanding Medicaid might mitigate those efforts and, even worse, make them look both stubborn and foolish for not acting in the best interests of TN residents and doing it years ago! The Governor and the TN Legislature should park their egos and do what's right for Tennessee residents. And this block grant plan proposal certainly doesn't qualify. Jerry O'Connor 2820 Rader Ridge Court Antioch, TN 37013 70 ocoandasoc@aol.com 71 Jonathan Reeve From: Sent: To: Subject: Maureen Schlacter Friday, October 18, 2019 12:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] block grant....NO   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Why would Tennessee cut $2 billion from TennCare when;  Tennessee has closed 12 Rural Hospitals, has 675,000 uninsured which includes 425,000 Children; Tennessee is one of  nine states to see an increase in the number of Children that have become uninsured in 2018; there is an increasing  number of Seniors needing long‐term care?     The Block Grant Proposal allows cuts of $2 billion from TennCare funds by actions such as; restricting or eliminating  physical therapy, hospice, and medicines without normal oversight; cuts back core services like hospital care and  emergency services without federal approval or public notice, and excludes coverage of some important prescription  drugs.             The Block Grand Proposal is simply a transfer of money from the patients and providers to Tennessee and Federal  Governments.    Tennessee is already at the bottom of health measurements such as infant mortality, maternal mortality and life  expectancy.  This proposal will do nothing to bring these numbers up.  This proposal is bad for Tennesseans.      Maureen Schlacter  6037 Brentwood Chase Dr.  Brentwood, TN 37027          72                73 Jonathan Reeve From: Sent: To: Subject: April L. Jackson Friday, October 18, 2019 12:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant opposition   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts:     I am writing to express my strong opposition to the Block Grant for Tennessee.  This proposal would be harmful to our  citizens, particularly the pregnant women, children and elderly who rely on TennCare for their health and  wellbeing.  Additionally, should the State decide to move ahead with this plan, there's no doubt there will be litigation,  which will cost money to the taxpayers, not save it.     Please listen to the citizens who have already voiced their opposition and abandon this proposal.     Thank you,     ‐‐  April Harris Jackson   Hermitage, Tennessee         74 Jonathan Reeve From: Sent: To: Subject: Thise Collins Friday, October 18, 2019 12:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Please do not block Tenncare grants for Mentally Ill and Disable     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear TennCare officials,    TennCare is important to [me/my family/my friend]. It provides comprehensive health care coverage for people in need.  TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential  health treatments and manage their condition.  TennCare has helped [me/my family/my friend] by [fill in with an  example that is particular to you]    I am concerned about the plan to change TennCare (Tennessee’s Medicaid  program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with  mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important  to people with mental illness.    More people need access to TennCare, not less.    I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not  hurt them.    Sincerely,  [Thise Collins  75 Jonathan Reeve From: Sent: To: Subject: Judy Lifsey Friday, October 18, 2019 12:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am opposed to the Block Grant proposal because I see the majority of Tennesseans oppose it while the Governor and Republican legislators push it through for reasons unexplainable. I earnestly relieve it is your attempt to remove people from the possibility of healthcare. That is definitely the way the proposal reads with limited possibility to add people as their needs change. Easy to remove, but hard to quality to enter. How many friends or neighbors have you known personality who depended on Tennessee government health funds for their continued life? Are you really aware of their struggles to continue getting these funds? I do and this new proposal appears to put more control of these funds in the hands of state lawmakers who continually disregard the wishes of the people of Tennessee in favor of their big buck supporters. Why aren't you, Governor Lee, appearing at the state meetings to hear the people, the doctors, the health associations and business leaders explain their opposition? Perhaps you need to pray about it. I do not believe we are the ones misinformed. Judy Lifsey, Franklin, TN Sent from Yahoo Mail. Get the app 76 Jonathan Reeve From: Sent: To: Subject: guymhicks@everyactioncustom.com on behalf of Guy Hicks Friday, October 18, 2019 11:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    It is critical to not put healthcare at greater risk in Tennessee. I am opposed to the proposal to radically change  Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into a “block  grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Guy Hicks  20 Wynstone  Nashville, TN 37215‐5800  guymhicks@gmail.com  77 Jonathan Reeve From: Sent: To: Subject: m johnson Friday, October 18, 2019 11:40 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant proposal comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Hello I'm from 37206. I do not support any legislation that would threaten healthcare for disadvantaged people. I think  state legislators are too closely related to big healthcare corporations like HCA. I believe public servants should institute  public programs that benefit the public over private interests. Many other countries do it and it works out fine. In fact I  had to go abroad for surgery this summer because I couldnt afford it here.   78 Jonathan Reeve From: Sent: To: Subject: kminault@everyactioncustom.com on behalf of Kent Minault Friday, October 18, 2019 11:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Kent Minault  311 W Glenwood Ave  Knoxville, TN 37917‐5601 kminault@gmail.com  79 Jonathan Reeve From: Sent: To: Subject: Linda Slobey Friday, October 18, 2019 11:26 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Against. Block grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   This sounds like another crazy scheme to deny helping those less fortunate than those who are making this decision. The  state needs to accept Medicaid expansion.    Linda Slobey  80 Jonathan Reeve From: Sent: To: Subject: mmiddl9469@everyactioncustom.com on behalf of Mary Jo Middlebrooks Friday, October 18, 2019 11:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal is contrary to the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It runs counter to the goals and purpose of the Medicaid  program. I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mary Jo Middlebrooks  PO Box 1985  Jackson, TN 38302‐1985  mmiddl9469@aol.com  81 Jonathan Reeve From: Sent: To: Subject: Jeff Krinks Friday, October 18, 2019 11:09 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment regarding Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To whom it may concern:    I would like comment on Tennessee's block grant proposal.    I strongly believe the proposal is a terrible policy and a dangerous experiment that threatens health coverage for thousands of Tennesseans. Instead the state should expand Medicaid.    Thank you for considering my comments and concerns.     Sincerely,  Jeff Krinks  Franklin, TN 37069    82 Jonathan Reeve From: Sent: To: Subject: Blake Leyers Friday, October 18, 2019 11:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] 1115 Demonstration Waiver   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts,    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.      For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,  Blake Leyers    5969 Hitching Post Lane  Nashville, TN 37211  83 Jonathan Reeve From: Sent: To: Subject: Rose Robertsonsmith Friday, October 18, 2019 11:08 AM PUBLICE NOTICE TENNCARE [EXTERNAL] do not support   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***       I do not support this change.  It will not be better for health care in the future  ‐‐   Rose Robertson-Smith  Idlewild Wool  Creating with recycled wool!  84 Jonathan Reeve From: Sent: To: Subject: Nora Katz Friday, October 18, 2019 11:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Tenn Care   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   This proposal makes health access less transparent and puts Tennesseans at risk of not be provided with needed  coverage.  I do not support this change.     Thank you,  Eleanor Katz  Nashville, TN  85 Jonathan Reeve From: Sent: To: Subject: Marty DeHart Friday, October 18, 2019 11:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I'm writing to register my opposition to the proposed health care block grant. It frankly doesn't pass the smell test.    This is a plan that does not benefit the people of Tennessee who need help the most. The state government's  fundamental job is to look out for all its citizens, including the poorest and neediest. The government's job is NOT to fill  its coffers with "savings". It's troubling and telling that the plan does not promise to dedicate this expected windfall to  furthering the healthcare coverage for Tennessee's population. So where would that money be going?    A far better statewide health care remedy would be true and honest Medicaid expansion, as that is certain to reach and  help the people who need such help the most. Covering that portion of the population in turn helps all Tennesseans, rich  or poor, by lowering overall healthcare costs which ripples through insurance premiums, medical bills, and throughout  the system. This has been incontrovertably proven by Medicaid expansion in many other states.    Martha DeHart  811 Russleo Drive  Nashville, TN 37209  86 Jonathan Reeve From: Sent: To: Subject: Michael Heinrich Friday, October 18, 2019 11:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 - Demonstration, Project No. 11-W-00151/4, "Block Grants"TennCare II   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   RE: Amendment 42 – Demonstration, Project No. 11-W-00151/4, “Block Grants”TennCare II I am writing in response to the Division of TennCare’s Amendment 42 draft waiver to change the financing structure for the TennCare program. As a former Tenncare recipient I am concerned that Amendment 42 makes promises that cannot be kept.   Specifically:   • • • Amendment 42 offers no guarantee that Tennessee will opt to cover additional people or provide better services to improve the health of Tennesseans. The onus of reducing costs is on TennCare beneficiaries, rather than pharmaceutical companies, managed care organizations, and/or administering agencies. There will be insufficient oversight of any program changes.   When Tennessee’s General Assembly passed legislation requiring the Division of TennCare to submit a “Block grant” waiver amendment, there was no discussion of using this waiver to provide coverage for additional people or provide additional benefits. There was no discussion of using this financing structure to address Tennessee’s most urgent health needs such as an increasing uninsured rate, access to care in rural communities, or addiction. In fact, nowhere is it written that the General Assembly, Governor’s Office, or the Division of TennCare are committed to improving the insured rate or improving specific health outcome measures for Medicaid eligible individuals.   Tennessee is one of only 14 states that have chosen not to accept Medicaid Expansion dollars as allowed by the Patient Protection and Affordable Care Act. This denial of $1.2 Billion dollars annually can be directly linked to increased vulnerability of rural hospitals, higher infant mortality rates, higher chronic illnesses, and stunted ability to address mental health and addiction concerns. Tennessee’s General Assembly has established a well-documented opposition to adopting policies or models that work to improve health outcomes. Any proposal that does not include health coverage of individuals with income up to 138% of the Federal Poverty Level (FPL) shortchanges Tennessee.   Amendment 42 repetitively references the claim that Tennessee operates one of the most costeffective Medicaid programs in the nation. While this may be true by some measures, it is important to note that Tennessee does not offer the same level of coverage and services as other states. For example, Tennessee is one of only three states that does not provide any form of dental coverage for adults. The Division of TennCare references wanting to provide dental benefits for pregnant women, however CMS already allows states considerable flexibility in providing benefits in targeted populations such as this. According to the Division of TennCare in Amendment 42 draft waiver, Tennessee is spending less than the Centers for Medicare and Medicare Services (CMS) projects on an annual basis. 87 Approving Amendment 42 rewards Tennessee for not providing benefits such as dental and could potentially incentivize other states to dropping dental coverage in the future. I support the idea that reducing costs is critical in the effort to sustain the Medicaid program and cover Tennessee’s working uninsured. As written, Amendment 42 focuses entirely on reducing costs in ways that will impact beneficiaries. In Tennessee there is no oversight of the Managed Care Organization (MCO) contracts and the contracts not publicly available. Amendment 42 should include a provision that MCOs have an appropriate Medical Loss Ratio. Shared savings should not go to greater profits and these contracts should be made publicly available as part of any comprehensive cost-savings effort. The onus of reducing costs should not rest on Tennessee’s most vulnerable people.   It has been my experience working with TennCare eligible beneficiaries, I routinely encounter situations in which eligible families are denied coverage, approved families never receive their insurance card, and people unknowingly lose coverage. The request of Amendment 42 to reduce CMS oversight without outlining how Tennessee will provide clinical and administrative oversight has made beneficiaries and the community-based organizations that provide services to these families understandably nervous.   When TennCare first transitioned to a Managed Care program, Tennessee Health Care Campaign served as an ombudsman to individuals who were eligible for Medicaid. This program was dissolved in 2005 when 170,000 adults were disenrolled because of a change in eligibility rules. Removing another level of oversight leaves Tennesseans more vulnerable and in the hands of state legislators who routinely attempt to tamper with the Medicaid program without regard to population health. Amendment 42 insufficiently explains how the Division of TennCare will legally maintain current eligibility and level of services in the event the Tennessee General Assembly decides to cut costs by changing eligibility or benefits.   In conclusion, I am concerned that the Amendment 42 draft waiver makes promises that it cannot keep. This waiver gives Tennessee’s General Assembly an unprecedented amount of control over the health of children and families eligible for TennCare. It does not address how this waiver will address any of Tennessee’s pressing health problems such as in increasing uninsured rate. It appears to unfairly target eligible beneficiaries to reduce costs without attention to managed care organizations, pharmaceutical companies, or administrative costs.   Respectfully,   Michael Heinrich 3712 Carrington Dr. Memphis, TN 38111 10/18/2019   88 Jonathan Reeve From: Sent: To: Subject: dacabutler@everyactioncustom.com on behalf of David And Carol Butler Friday, October 18, 2019 10:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. David And Carol Butler  35 Asbury Ln  Hermitage, TN 37076‐2166  dacabutler@gmail.com  89 Jonathan Reeve From: Sent: To: Subject: Sharon Petke Friday, October 18, 2019 9:52 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the block grant proposal. Here are my reasons.   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   1) It would provide flexibility, but that would lessen the provision of core care now guaranteed by the federal government. See figure 1. 90 There’s plenty of flexibility beyond the core care currently required by CMS. A block grant would eliminate the requirement for core care, which is where “more flexibility” would apply. 2) So if flexibility is removed, what is the reason for the change? Money. The money that is now going to the federal government would come to the State, which they say in Tennessee’s hands would be applied to state Medicaid programs. I’d like to see more detail around that claim. Interestingly, I couldn’t find anything on TN.gov about this plan in order to learn more about how and to what they would apply those savings. 3) Speaking of money, Tennessee could get more of it for its Medicaid program right now by accepting ACA’s expansion, and it wouldn’t cost the state a dime. This would cover 300,000 of vulnerable, uninsured working people who don’t qualify for ACA without the expansion, but make too much to be eligible for TennCare. It would also save hospitals and create jobs. Therefore, I’m skeptical that their aim is to use savings to help more people. Gov. Haslam was in favor of it, but the Committee on Finance (not Health committee) shut it down and it has never 91 come to the floor of the General Assembly. Even though an April 2018 poll showed that registered Tennessee voters favor it by 3 to 1. https://www.tnjustice.org/bring-it-home-tennessee/ and https://www.tnjustice.org/wpcontent/uploads/2018/10/Bring-It-Home-Talking-Points-Sept-2018.pdf 4) Here is an interesting page. https://www.americashealthrankings.org/explore/annual/state/TN/view/adjustmy-rank Choose a ranking you wish we had. (I chose 25.) At the bottom, hit the button to “edit categories.” Then choose “uninsured” and any others you want to see. I chose Drug Deaths, Children in Poverty, Preventable Hospitalizations, and Premature Deaths. Move the “uninsured” category towards 0 and watch what happens to all the other categories. They all went down. If you choose other categories, such as Public Health Funding, they might go up because there are more people alive. But overall that’s what we want, right? 5) I guess it boils down to, Who do you trust? Here’s a post from a group I trust. The Tennessee Justice Center is a non-profit public policy advocacy organization and law firm based in Nashville, Tennessee. It was established in 1996 to represent approximately 1.3 million Tennessee low-income families by helping shape public policy and through class action lawsuits. https://www.tnjustice.org/medicaid-block-grants-in-tennessee/ Des       Enjoy The Lord!  Sharon Petke  5405 Heritage Ln  Kingsport TN 37664  sspetke@me.com        92 Jonathan Reeve From: Sent: To: Subject: susanhathcock@everyactioncustom.com on behalf of Susan Hathcock Friday, October 18, 2019 9:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    This is an awful idea.  It is unkind, unChristian, and unAmerican.  Is this how you want to be remembered?  Tennesseans  will not forget how you act in this dire situation.    Sincerely,  Mrs. Susan Hathcock  303 E 2nd Ave  Lenoir City, TN 37771‐2511 susanhathcock@gmail.com  93 Jonathan Reeve From: Sent: To: Subject: daviscrew03@everyactioncustom.com on behalf of Amy DavisIsbill Friday, October 18, 2019 9:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amy DavisIsbill  2146 Mentor Rd  Louisville, TN 37777‐4003 daviscrew03@yahoo.com  94 Jonathan Reeve From: Sent: To: Subject: Tosha Downey Friday, October 18, 2019 9:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] No block grants. Expand Medicaid.   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   This passage from Matthew 25 is important for context:    When the Son of Man comes in His glory, and all the [a]holy angels with Him, then He will sit on the throne of His glory. All the nations will be gathered before Him, and He will separate them one from another, as a shepherd divides his sheep from the goats. And He will set the sheep on His right hand, but the goats on the left. Then the King will say to those on His right hand, ‘Come, you blessed of My Father, inherit the kingdom prepared for you from the foundation of the world: for I was hungry and you gave Me food; I was thirsty and you gave Me drink; I was a stranger and you took Me in; I was naked and you clothed Me; I was sick and you visited Me; I was in prison and you came to Me.’    “Then the righteous will answer Him, saying, ‘Lord, when did we see You hungry and feed You, or thirsty and give You drink? When did we see You a stranger and take You in, or naked and clothe You? Or when did we see You sick, or in prison, and come to You?’ And the King will answer and say to them, ‘Assuredly, I say to you, inasmuch as you did it to one of the least of these My brethren, you did it to Me.’    “Then He will also say to those on the left hand, ‘Depart from Me, you cursed, into the everlasting fire prepared for the devil and his angels: for I was hungry and you gave Me no food; I was thirsty and you gave Me no drink; I was a stranger and you did not take Me in, naked and you did not clothe Me, sick and in prison and you did not visit Me.’    “Then they also will answer [b]Him, saying, ‘Lord, when did we see You hungry or thirsty or a stranger or naked or sick or in prison, and did not minister to You?’ Then He will answer them, saying, ‘Assuredly, I say to you, inasmuch as you did not do it to one of the least of these, you did not do it to Me.’ And these will go away into everlasting punishment, but the righteous into eternal life.”  The sickest, the poorest, and the neediest—this is who is covered by TNCare. My father is one of those sickest, poorest, and neediest. Until 5 months ago, my dad was a pillar in the neighborhood where we've lived our entire lives; he's served his country in the US Navy. He's spent the last 53 years of his life in partnership with my mother. He was a deacon, little league coach, and "granddad" to hundreds of children in the church programs run by Christ Quest. And after a fall on June 11th, he went into cardiac arrest, and now suffers from a permanent brain injury. He requires 24 hour care. He's been in 3 hospitals and 2 nursing homes. The fight to get quality care for him has been exhausting.     95 Expanded Medicaid is what other elderly poor people we need—not block grants. This week we had a meeting in which my mom and I were preparing for the discharge of my father and figuring out how the two of us would provide the same 24 hour care that he's received for the last five months. I may have to move out of my house, move home with my parents, take medical leave, and care for my father. Reduced service and reduced availability of providers has been my life story in a way I could not have imagined.     Expanded Medicaid is what Tennessee’s most vulnerable citizens need—not block grants.    I have a bachelor's, master's, and law degree; and just navigating eligibility requirements, finding a provider to accept my dad, ensure that he's getting adequate care, not to mention that the processes has been traumatic, time-consuming, and disheartening. I can't imagine how my mother who lives with a disability would navigate this process and manage my father’s care. I also can't imagine how 200k poor mothers tried to negotiate this when their babies were kicked off the TN CARE rolls.     Tennessee needs expanded Medicaid not, block grants. TN should not be exempted from federal oversight. I hope that our state prioritizes saving lives over saving money.    Thank you,  Tosha Downey  96 Jonathan Reeve From: Sent: To: Subject: daviscrew03@everyactioncustom.com on behalf of Amy DavisIsbill Friday, October 18, 2019 9:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment opposing this proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amy DavisIsbill  2146 Mentor Rd  Louisville, TN 37777‐4003 daviscrew03@yahoo.com  97 Jonathan Reeve From: Sent: To: Subject: jhscrs@everyactioncustom.com on behalf of James Sewell Friday, October 18, 2019 9:23 AM PUBLICE NOTICE TENNCARE [EXTERNAL] A block grant without specific details about coverages and elgibility would be open to mis;management. It could also mean that many who need health care the most would be left out. Pleased be reminded that Medicaid was created to help people,.     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rev James Sewell  1027 Davidson Rd  Nashville, TN 37205‐1023 jhscrs@bellsouth.net  98 Jonathan Reeve From: Sent: To: Subject: Jerry Laster Friday, October 18, 2019 9:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] The Medicaid Block Grant proposal is the worst or should I say the DUMBEST idea any politician could have ever had. It will destroy the sick and poor people of Tennessee. I hope it is challenged in court if passed. Jerry A Laster   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***       Sent from Windows Mail      99 Jonathan Reeve From: Sent: To: Subject: Rachel Clark Friday, October 18, 2019 8:29 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenncare Funding   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern:    I am a resident and voter in the state of Tennessee. I am writing to oppose Governor Bill Lee's proposal to curtail  Tenncare funding. I work multiple part‐time jobs, none of which offer health insurance. I am the full‐time caregiver for  my fourteen‐month‐old son. I rely on Bluecare as my sole source of health insurance. Attempting to siphon away funds  from Tenncare will hurt working women and their children, who are respectively the backbone and future of our  communities.    Sincerely,    RLC  100 Jonathan Reeve From: Sent: To: Subject: celiajoyner@aol.com Friday, October 18, 2019 7:22 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please vote no to block grants  Celia Joyner  Brentwood, TN  101 Jonathan Reeve From: Sent: To: Subject: mcb@everyactioncustom.com on behalf of Mary Agee Thursday, October 17, 2019 10:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Sir, I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” Why are we allowing Tennessee to get LESS from the  federal government due to the inane proposals!  This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     My parents worked their whole lives but at very low wages.  They never took any handouts!  Yet in old age they needed  TENNCARE!  Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable  Americans get vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives  Tennessee new authority to cut services for these vulnerable populations. The state could eliminate or restrict services  like physical therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets  them. The proposal could also cut back on ALL core health care services!    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     Please listen to those who have used or needed these services and not the wealthy who have no idea of the need!!      Sincerely,  Mary Agee  Carthage, TN 37030  mcb@dtccom.net  102 Jonathan Reeve From: Sent: To: Subject: psimon901@everyactioncustom.com on behalf of Elaine Simon Thursday, October 17, 2019 9:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Elaine Simon  75 Mitchell St  Hornsby, TN 38044‐4045  psimon901@aol.com  103 Jonathan Reeve From: Sent: To: Subject: Grace Smith Thursday, October 17, 2019 9:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on TN Medicaid block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Thank you for the opportunity to comment on the Medicaid block grant proposal. On behalf of the Council on  Aging, I want to acknowledge the state's desire to be innovative, to address prevention and social  determinants of health, and to improve rural health. It's also admirable that the proposal aims to create a  shared savings with the federal government through effective administration.    Despite these positive elements of the proposal, I want to express overall opposition to the block grant  proposal due to capping federal funds and a lack of specificity in several parts of the proposal which will likely  lead to unintended consequences for the state's most vulnerable populations. For example, the proposal does  not specify how savings will be achieved nor how they will be spent. It is not clear what population of elderly  will be impacted by the block grant despite the carve out of dual eligibles, nor is it clear whether the state will  seek to waive federal oversight and protections that help ensure quality of long term care. We are very  concerned about the potential unintended consequence in nursing home quality.    We are also concerned about the closed drug formulary, especially the suggestion that one drug per class be  covered.    We urge officials to seek an independent fiscal review before proceeding with the proposal, especially given  indications from the federal level about cutting Medicaid spending. It's also vital to consider solutions that  address the larger issues of 300,000+ uninsured Tennesseans, and the rapidly growing older population and  need for a much stronger system of home and community supports and long term care.     Our organization shares the Governor's commitment to ensuring that every Tennessean has access to high  quality health care they can afford, and we believe that TennCare is a vital part of fulfilling that commitment.    In conclusion, given the Trump administration's intent to cut federal funding for Medicaid, it's imperative that  the state avoid any plan that could cap or reduce federal Medicaid dollars and have unintended consequences  for vulnerable Tennesseans.    Respectfully submitted,    Grace Smith      104     105 Jonathan Reeve From: Sent: To: Cc: Subject: Katelyn Prince Thursday, October 17, 2019 9:23 PM PUBLICE NOTICE TENNCARE Jessica Hejny [EXTERNAL] Comment on Demonstration Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Tennessee is proposing a change to the way in which they receive federal Medicaid funding. It would turn the funding into an altered version of a block grant that would provide funding in an annual lump sum. Currently, the federal government funds a certain percentage of healthcare costs per qualified individual Medicaid recipient. This system would effectively free the state from Medicaid restrictions imposed by the federal government and provide complete autonomy. As is, there are requirements and rules attached to funding. The proposal would allow the state to choose who and what is covered. In addition to this, the state would retain half of any money not spent. They also included the provision of extra funds in the event of more enrollments that could potentially exceed funds.   The TennCare proposal is seemingly reasonable. It is very straightforward in that it clearly lays out the goal of  gaining absolute discretion and really making cost effective decisions. It is hard to argue against the idea of  saving money in order to help more people. However, the obviousness of the intention to cut back and turn  this into a major savings area does raise some concerns. In order to become more “cost effective” it would  quite possibly require cutbacks that could potentially hurt those already receiving coverage, even if that is not  the intention. The intention seems to be to save money so that the program can be expanded on Tennessee’s  own terms, but that seems a little counter-intuitive when there are already some people who are not covered.  Work requirements can not always be met, as reasonable as they seem. There are also many other factors  that may bar people from receiving healthcare coverage. So, to make it the state’s choice on how and to who  TennCare is dispersed, without overt oversight from the federal government or regulations in compliance with  Medicaid, leaves some room for doubt on whether it will be successful or just upset and potentially harm a  number of people. Another concern is that one very simple cost‐cutting measure may be very harmful. The  option of only covering one or fewer medications of the same relative type, due to their cheaper prices, is a  tempting but tricky notion. In many instances, a person may not respond to the cheaper medication as well,  leaving them with the option to either pay for the one that is more effective, or take the one they can afford  but does not help them in the way they need. Yes, such an instance may be a little more rare, but it still  warrants great consideration. If this modified block grant were to work, it would have to be administered in a  way that did not hurt the very people it is supposed to help.     106 Jonathan Reeve From: Sent: To: Subject: cmaland@everyactioncustom.com on behalf of Charles Maland Thursday, October 17, 2019 9:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans and it would fail to address the most significant problem in health care in the state‐‐tens of  thousands of Tennesseans without any health insurance at all.  When those folks get desperate enough, they go the  emergency room for far more expensive care than should be the case.  Then they're unable to pay for treatment, and  the premiums for all the rest of us go up.    This proposal does nothing to address this problem.  Expanding Medicare, which most states had the good sense to pass  years ago (and whose populations are healthier than ours), is what the state should be doing.     Plus, there's no way the Federal Government should approve this flawed proposal, although the President and his  administration are so fatally inadequate in terms of its health care record, that they might just let it slip by and then  count it as a "victory."  Then Tennessee would be stuck with another inadequate health care scheme of the sort we've  seen coming out of Nashville for the forty years I've lived in Tennessee.    When the next recession hits, there will be countless folks thrown off health care OR benefits will be trimmed   or both.    Stop wasting time with block grants.  Expand medicare.        Sincerely,  Charles Maland  427 Oakhurst Dr  Knoxville, TN 37919‐6642 cmaland@utk.edu  107 Jonathan Reeve From: Sent: To: Subject: Keeli Crewe Thursday, October 17, 2019 9:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Please Reject Governor Lee’s Modified Block Grant for Tenncare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   There are 675,000 Tennesseans who go to bed each night without health insurance ‐ 20,000 of them are here in  Chattanooga. There are 65,772 Hamilton County residents enrolled in TennCare. Nearly 90% are women and children.  The remainder are nearly all elderly, blind, or have severe disabilities.  Under Governor Lee's "modified" block grant, the State will continue to get funding from the federal government as  membership grows ‐‐ but if TennCare spends less than the federal government gives it, Tennessee state government can  keep half of the extra money.   This means that the state government, which already provides among the stingiest benefits to the working poor, will  have an incentive to cut those benefits even further. This is not acceptable.   Chattanoogans shared with our Mayor, Andy Burke, the things that actually worry them: the rise in the number of  people who are uninsured, despite working as hard as they can. The opioid crisis. Growing medical debt. The constant  fear of losing coverage because of pre‐existing conditions. None worry about how much money state bureaucrats could  save by cutting health coverage for Tennessee's most vulnerable families.  Tennesseans need care and coverage, not experiments that will lead to cutting corners in the name of cost‐saving.  We hope the federal government should reject this dangerous proposal.    Keeli Crewe, Chattanooga, TN  423.598.9810 c  keeli.crewe@me.com    [via iPhone]  108 Jonathan Reeve From: Sent: To: Subject: GARY & MARY RUSSELL Thursday, October 17, 2019 8:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom it may concern, I am the parent of a handicapped adult who has been that way since he was a child. He was contacted by United Healthcare about the CHOICES program. He was told he had to be handicapped since he was under the age of 18 (check), had to have a IEP showing he participated in a 504 program as a child (check) AND demonstrate a need for services provided by the CHOICES program (check.) We gave them all the relevant information and waited to hear back from them... and waited... and waited. Finally he received a letter from them stating he did not have a valid IEP and was ineligible for the program. Money was wasted to justify three people's jobs, NOT to help the ONE person who needed it the most. We have a BIG lawsuit against the state of Tennessee AND United Healthcare because my son was denied services. Tennessee is NOT capable of handling a Block grant effectively and for the best interest of the people who need it most without oversite. You brag about how good healthcare is in this state while you send children/adults with Diabetes to the health department to see a nurse when they should be seeing a Endocrinologist. You place indigent bedridden people in nursing homes that are not fit to care for animals and give them passing grades just to say "look at me and how much money I saved Tennessee." Rehab facilities put patients in beds they are not able to raise themselves up and down, but have to wait for someone to come and crank them up and down. They are made to wait up to six hours to be catheterized in order to urinate (those without a Foley.) If they are a patient at U T their items they their insurance pays for (cream, bandages, cleanser, etc...) is stolen from them in the middle of the night by aides and nurses and repurposed (yes, upper management is aware it goes on). That is insurance fraud. That is Tenncare fraud. Tennessee cannot be trusted to use a block grant in a manner that will benefit those who need it most. These are just a few examples of how Federal monies are wasted WITH oversite. I shudder to think what healthcare would look like WITHOUT oversite. Instead of trying to hurt the citizens you represent, try applying for a grant to build assisted living facilities (NOT group homes) where people with Diabetes etc. could live and learn to take care of themselves (i.e. cooking healthy meals, having people to make friends with, have onsite access to doctors and medications, exercise programs and outings. This could be done with a minimum of monetary outlay by utilizing doctors/ nurses/Dietician's who are just starting out. The carrot would be loan forgiveness after a five year commitment.The biggest enemy people with health problems is isolation. The second biggest is people taking advantage of them for their money. Fix the numerous problems this state already has BEFORE you try to police yourselves. 109 Jonathan Reeve From: Sent: To: Subject: Rondi Kauffmann Thursday, October 17, 2019 7:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant proposal comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Gabe Roberts, Director   Division of TennCare   310 Great Circle Road  Nashville, TN 37243       Dear Director Roberts,     I am submitting the following comments regarding the proposed Amendment 42 to convert federal funding for TennCare into a block grant.     My name is Rondi Kauffmann, and I am mom to a medically fragile, disabled child who is not currently on TennCare, but would qualify under the Katie Beckett waiver program. Specifically, the following statement :   Page iv: “The costs associated with any new population the state opts to cover in the future, even if it would otherwise be considered a core population, will be excluded form the block grant calculations for a period of years until the state has enough experience paying for services for this population to update the block grant formula in a financially sound manner.” This continues on Page 11 Avoiding Disincentives for Future Program Changes: “the state anticipates that such expenditures would be financed outside of the block grant via the traditional Medicaid financing model for a period of up to three years. Once the state and CMS have sufficient experience with the program modification, the state’s block grant amount will be adjusted accordingly so that the new expenditures can be integrated into the block grant.”   I understand that this means that new programs, =including Katie Beckett, will not be included in the block grant for up to three years. However, at that time, the funding for the program will be allotted for the future program through the block grant. This will make it very hard to expand services covered, or serve additional children.     In addition, our daughter has a significant condition that leads to death in 90% of children by the age of 2. There is no cure, and until 2 years ago, there was no treatment. There are now two treatments that can extend both length of life and quality of life for children affected by Spinal Muscular Atrophy (SMA) like our daughter, but both treatments are expensive. The proposal specifically requests that TN be allowed under the Block grant to choose to NOT cover new or expensive medications, until there is sufficient experience/data to show cost/benefit. Many conditions are rare, and therefore, it takes many years to accrue enough children who have been treated to show definitive evidence of benefit, even if the benefit is noted for individual children right away. I am extremely concerned that 110       this proposal, as written, will limit access to these life‐saving medications for children who will die without them, just because they are expensive, and the time it takes for scientific data to be published may be prohibitively long.     While measures to guide wise use of health care resources are necessary, it is my opinion that the TN Medicaid Block Proposal puts the people of the state of TN, particularly the disabled and vulnerable/medially complex children at risk for falling further and further behind other states in terms of health care provided.            Sincerely,  Rondi Kauffmann, MD, MPH  o 111 Jonathan Reeve From: Sent: To: Subject: jamie gaines Thursday, October 17, 2019 7:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] No to block grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Sir or Madame:    I ask you can deliver this message to Tennessee's esteemed Governor: we need more resources towards healthcare, not  less. We need more access to information on rates and negotiated fees. We need not enter murky, uncharted waters  that leave those most vulnerable to drown without the slightest of ripple. People are suffering enough as it is navigating  this life with health needs, we must act with discernment and compassion when making decisions that affect them.     I ask the Governor to do as Christ would do.     Mercy.   Always mercy.     With hope,   Jamie C. Gaines  Signal Moutntain, Tennessee  112 Jonathan Reeve From: Sent: To: Subject: diane.keeney@everyactioncustom.com on behalf of Diane Keeney Thursday, October 17, 2019 5:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Diane Keeney  1603 Stokes Ln  Nashville, TN 37215‐1511 diane.keeney@gmail.com  113 Jonathan Reeve From: Sent: To: Subject: pacarbone99 Thursday, October 17, 2019 4:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please stop the block grants. What if it were your child who needed medical care without having adequate healthcare insurance?    Andrea and Patrick Carbone        Sent from my U.S. Cellular® Smartphone  114 Jonathan Reeve From: Sent: To: Subject: Joshua Gross Thursday, October 17, 2019 4:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Oppose Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom it May Concern,    Bill Lee's "modified" block grant proposal is unacceptable and irresponsible. Please reject such a dangerous proposal.    Best,  Josh & Jen Gross  227 Eveningside Drive  Chattanooga, TN 37404  115 Jonathan Reeve From: Sent: To: Subject: Arden Woods Thursday, October 17, 2019 4:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Proposal for TennCare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am writing to say that I do not agree with Gov. Lee's block grant proposal for TennCare. I am concerned that the governing of this as written will lead to cutting corners and reducing services for the most vulnerable and needy in the name of cost-savings for state government. Thank you,  Deranda McDade  1818 Skyline Dr.  Chattanooga, TN 37421  116 Jonathan Reeve From: Sent: To: Subject: Chase Eustice Thursday, October 17, 2019 3:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Proposal for TennCare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good afternoon,   I’m writing this in concern to the Block Grant Proposal for TennCare made by Gov. Lee. As a lifelong Tennessean and Bill  Lee supporter I cannot agree with a proposal that will incentivize the state government by denying coverage to those in  need. I don’t always agree with Mayor Berke of Chattanooga but in his recent bulletin he said     “ Tennesseans need care and coverage, not experiments that will lead to cutting corners in the name  of cost Savings”  I could not agree more with this statement     Thank you for taking the time to read this and have a wonderful day.    Chase Eustice   423‐664‐2527           ‐‐   Chase Eustice  423‐664‐2527  117 Jonathan Reeve From: Sent: To: Subject: tnpowfam@everyactioncustom.com on behalf of Liz Powell Thursday, October 17, 2019 2:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    i Have a special needs child who is 7 years old.  We adopted him out of the  tn foster care system because we believe  that EVERY child is special.  He needs a lot of medical care and we are trusting that the state of tn will continue to  provide him with the best care!             Please remember that those of us with children with special needs also have  special medical needs!       I have read about the block grants and it does not seem like it will be the best for us, but  maybe I don’t understand it as well as you do.  Just please make sure our kids are fully covered with no interruption in  their services or medical needs!  Including all therapies, doctor and hospital visits, and growth hormone and other  medications.  We have been very happy with the current program, and if it was up to us, we would not vote for any  changes.  Thank you.                        Sincerely,  Liz Powell  535 Laurel Park Cir  Cookeville, TN 38501‐3017 tnpowfam@gmail.com  118 Jonathan Reeve From: Sent: To: Cc: Subject: Melinda Hardison Thursday, October 17, 2019 3:21 PM PUBLICE NOTICE TENNCARE Jessica Hejny [EXTERNAL] Comment on Demonstration Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   The Amendment 42 draft proposes replacing the Medicare system currently in place with a modified block grant. These proposed changes will include the federal government paying Tennessee a predetermined lump sum every year, which should rise with inflation and the needs of citizens. Any savings on the part of the state will then be split between the state and federal governments. This, according to the draft, will “streamline” healthcare in Tennessee and incentivize the state to save money. The concern here is the fact that the most glaringly obvious way the state can save money is by denying coverage to citizens. The draft reads “no reductions on who is eligible for or what benefits are currently provided in TennCare,” yet there is nothing to stop the state from amending TennCare to reduce coverage once the proposal is approved. The proposal clearly states that relief from federal requirements is the goal. Currently, the federal requirements that Tennessee must follow include minimums on who it allows into the system and what healthcare is covered. These are what draft 42 calls “unnecessary administrative and regulatory boundaries.” The fact that the state wants to skirt these minimums brings their motives into question. Tennessee is one of fourteen states that chose not to expand Medicaid to those whose household income is below 133% the federal poverty level and therefore does not have an impressive track record with prioritizing the health of its citizens. Another major concern is that the draft proposes to limit access to prescription drugs by eliminating drugs in instances in which there is more than one drug that does the same thing. What is being neglectfully overlooked here is that some people have allergic and other reactions to additives that can be present in one drug and not another of the same category. This is especially true but not limited to generic vs non-generic drugs. This would seriously limit the choices and discretion citizens have pertaining to our own individual healthcare needs, putting lives and livelihoods at risk This proposal, which is being spun and marketed to us as a “freedom” is nothing more than the state making money as the expense of the people. Health is not something to be experimented with, and it will be the citizens and not the state who assume the primary risk. For all these reasons, I oppose the proposed changes to Tennessee’s Medicaid program.   119 Jonathan Reeve From: Sent: To: Subject: Kristen Davis Thursday, October 17, 2019 3:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Waiver Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Gabe Roberts, Director   Division of TennCare   via email to: public.notice.tenncare@tn.gov     RE: TennCare Waiver Amendment 42     Dear Mr. Roberts,     I am submitting the following comments in response to the public notice inviting public comments on proposed Waiver  Amendment 42.  Prevent Child Abuse Tennessee (PCAT), is a statewide non profit organization devoted to ensuring  children have safe, stable and nurturing environments and homes in which to grow.  We are committed to families and  their children, and the promise of prosperity into the next generation.  Our evidence based programming includes home  visiting, parent education, and a statewide domestic violence hotline.  We work with high poverty families in their  homes and communities to ensure they have the tools and education to raise their children in a healthy and nurturing  home.    We are unequivocally opposed to this proposal that would radically change Tennessee’s Medicaid partnership with the  federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.      This proposal could end up cutting the safety net for some of the most vulnerable families, children and seniors  in Tennessee. By putting a cap on federal funds for TennCare, state officials will be choosing who can get health  care, and who can’t.    We need TennCare to play a role in helping parents being able to raise their kids. TennCare helps parents to deal  with physical ailments, addiction problems, etc.   We can’t talk about the state’s role in healthcare without TennCare being at the center of that conversation. The  block grant has potential to cut off options and avenues for changes that would help all Tennesseans get access  to affordable healthcare.    Children have been disenrolled from TennCare at alarming rates, and losing coverage can mean the difference  between life and death for a family in poverty.      Families and communities are successful when they have access to healthcare for the adults and children.  This block  grant threatens to undermine the health and safety of families across the state, all while costing the state even more  money.  According to Governor Lee, the goal of this proposal is to generate $2 billion in savings. However, the proposal  points out that the state already “operates one of the most cost‐effective Medicaid programs in the nation.”  We are  unclear where these cost savings would be generated from.     The families and children we serve in our prevention programming would be negatively impacted by this proposal. The  mother struggling to provide food for her child with diabetes, the father who needs access to addiction services to be  present for his children, the grandparent raising their grandchildren who need healthcare to ensure their grandchild has  120 access to the essential mental health provisions, all of these families will be set on a path of struggle and hardship.  We  respectfully urge you not to go forward with this harmful proposal.     I can be reached for further questions or comments at this email address or the phone number below.  Sincerely,   Kristen    Kristen Davis, LAPSW President and CEO Prevent Child Abuse Tennessee 600 Hill Avenue, Suite 202 Nashville, TN 37210 615.383.0994 tel 615.383.6089 fax 1-800-356-6767 Tennessee Helpline kristen.davis@pcat.org Learn more at www.pcat.org   Any information transmitted in this e-mail is intended for the person or entity for which it is addressed and could contain confidential and/or privileged information. Any review, retransmission, dissemination, or other use of, or taking any action in reliance upon this information by persons or entities other than the intended recipient is prohibited. No waiver of confidentiality or privilege is granted by any error in transmission. If you have received this message in error, please contact the original sender and delete this material from your computer.       121 Jonathan Reeve From: Sent: To: Subject: joeinterrante@everyactioncustom.com on behalf of Joseph Interrante Thursday, October 17, 2019 2:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposition to Medicaid Block Grant--It will jeopardize health care for vulnerable Tennesseans     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     As a person living with HIV who has worked in HIV/AIDS services for the past 25 years, my experience has been that the  state requires greater oversight, not less, to preserve access to health care for those vulnerable populations for whom  the Medicaid program was designed.    In 1994, Tennessee secured an 1115 waiver to expand eligibility to Tennesseans who were uninsured due to low income  or “uninsurable” due to a “preexisting health condition.  By the late 1990s, costs of the program (called TennCare) had  risen significantly.  A good deal of this rise was due to the failure of some of the managed care organizations around  which the expansion had been organized.  Rather than looking to corrective action to improve MCO performance,  the  state simply cut the uninsured population from the program.  This removed poor but healthy individuals, leaving only  those with serious health conditions (the uninsurable) eligible, in effect turning the 1115 program into essentially a high‐ risk insurance pool.  Costs continued to rise (no surprise).  The response of the state in 2005 was to cut the uninsurable  population from the program. In the years since 2005, the TennCare program has become one of the narrowest  Medicaid programs in the country in eligibility and benefits.    As a result of the 2005 changes, about 1,000 Tennesseans living with HIV lost  Medicaid coverage which they had been  using to access HIV treatments as well as care.  The following year, our state’s Ryan White HIV Drug Assistance Program  (ADAP) was forced to create a waiting list for the first time in over 10 years.  Fortunately, the waiting list was eventually  eliminated due to the advent of Medicare Part D, and creation of a Ryan White Insurance Assistance Program in  combination with the Affordable Care Act.     The state had never fully acknowledged the administrative issues that contributed to TennCare’s fiscal difficulties. Its  consistent “solution” has been to restrict eligibility, and reduce coverage and/or services.  Given state leaders’ focus on  “savings” (of $1 billion or more) as the primary goal of the block grant, further cuts and restrictions will result.     In addition, the TennCare Bureau has experienced other repeated problems in enrollment, dis‐enrollment, appeal  review and other areas that have at times required court action to ensure corrective action.  Giving the state non‐ reviewable exemption from the federal requirements central to the Medicaid program will jeopardize both coverage  and services for vulnerable Tennesseans‐‐mainly children, pregnant women, and adults with disabilities.  I urge CMS to  reject Tennessee’s block grant proposal.    Sincerely,  DR. Joseph Interrante  122 2821 Hillside Dr  Nashville, TN 37212‐4101 joeinterrante@att.net  123 Jonathan Reeve From: Sent: To: Subject: Susan Gallo Thursday, October 17, 2019 2:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL]   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the block grant proposal for TennCare in Tennessee.  Legislators have villainized the poor to justify your lack of  compassion.  Prove me wrong by turning down this awful change to the system.   If State legislators accepted the  Medicaid expansion under the ACA, we would not be having this conversation!  124 Jonathan Reeve From: Sent: To: Subject: Suzanne Marsh Thursday, October 17, 2019 2:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am concerned that Tennessee is not a subject matter expert with regard to providing health care services.      We have had TennCare since 1994.  I do not believe the health statistics will support an improvement in the health of  our residents with TennCare. TennCare disenrolled 128,000 children over a two year period.  TennCare could not  identify those cut for lack of paperwork.  TennCare mailed out a hard copy of a mandatory form reportedly 80 pages  long.  Just this year, Tennessee rolled out an on line or over the phone enrollment  process.       https://www.publicnewsservice.org/2019‐07‐08/health‐issues/tennesseans‐losing‐medicaid‐state‐hasnt‐ bounced‐back‐from‐software‐failure/a66992‐1    Tennessee has not improved the health of its residents as a  whole.  https://www.tennessean.com/story/news/local/williamson/2018/10/02/tennesseans‐health‐below‐average‐ and‐its‐costing‐billions‐nonprofit‐says/1499143002/    https://wreg.com/2019/02/20/report‐85‐percent‐of‐tennessee‐maternal‐deaths‐preventable/      https://www.tnjustice.org/wp‐content/uploads/2018/09/Infant‐and‐Maternal‐Mortality‐Policy‐Brief.pdf      Tennessee is no doubt a leader in for profit health care companies and tech start ups.  With that as a backdrop, look at  what residents in Tennessee face when health care is needed:  https://www.washingtonpost.com/national/the‐clinic‐of‐last‐resort/2019/06/22/2833c8a0‐92cc‐11e9‐aadb‐ 74e6b2b46f6a_story.html      Tennessee is not doing an acceptable job providing essential health services to Tennessee residents.  Tennessee and  TennCare have not been successful in improving health as measured by chronic diseases, women's' and children's  health, maternal and infant mortality rates.      Why should Tennessee receive money free of federal oversight?    If Tennessee was demonstrating measurable improvement in the heath of Tennesseans and the actual delivery of  services was something we could be proud of, I would say Tennessee would be ready to be free of oversight.  However,  that is not the situation.      Suzanne G. Marsh  Clarksville, Tennessee     125 Jonathan Reeve From: Sent: To: Subject: dglyndavies@gmail.com Thursday, October 17, 2019 2:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  To whom it may concern,    I am vehemently opposed to Amendment 42.    I find it extremely concerning that the state of Tennessee would consider taking less federal money for the purpose of  helping the neediest of our citizens. There are more than 675,000 Tennesseans with no health care, more than 20,000 of  them in my hometown of Chattanooga. This is a partisan assault on the Affordable Care Act. Our state should be  considering expansion of Medicaid, not the opposite!    This is elitist legislation that will do harm to those who are unable to stand up for themselves. It would force more  people off of TennCare. Cutting health care is both a moral issue and an economic issue. It is an ill conceived notion to  move this legislation forward without the blessing of the medical professionals. The Tennessee Medical Society was not  even consulted in drafting this legislation!    Our state has the highest number of people in the United States who have had to declare bankruptcy because of being  unable to pay medical bills. Is this something that Governor Lee is proud of? Does he care at all about the plight of these  folks or is he sitting in his ivory tower counting his gold coins?    Bill Lee just wants to be able to get the money and have no federal regulation, while reducing the quality of care for  people in need.     It is shameful that this amendment is even being considered. I’m embarrassed to live in a state whose governor cares  more about partisan politics than the citizens who put him on office.    Obviously, I strongly oppose this idiotic legislation! Medicaid expansion is what we need and deserve, along with the  federal oversight that insures the money is being spent for it’s intended purposes.    Please do not allow this block grant legislation to pass.    Sincerely,    Diana Davies  806 Vine Street   Chattanooga, TN 37403  (703) 764‐0907  1 Jonathan Reeve From: Sent: To: Subject: Leslie Morris Thursday, October 17, 2019 2:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] block grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Gov. Lee’s determination to reduce the number of low income citizens who need TennCare but changing it to block  grant funding is a terrible and cruel plan. We should be expanding Medicaid, not doing the reverse. Please stop him from  harming Tennesseans who deserve to have health care! The state legislature already stockpiles millions that could be  used to help children and families, so they don’t need to try and hold back more. It’s uncomcionable!    Leslie Morris  Chattanooga TN 37405  2 Jonathan Reeve From: Sent: To: Subject: Mary Frances Clark Thursday, October 17, 2019 1:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Tennessee block grant proposal for Medicaid funding     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I oppose the proposed plan to change Tennessee”s Medicaid program by converting federal funding for TennCare into a  block grant arrangement.    As an attorney, I question whether there is legal authority for such an arrangement.  The statutory provisions for  Medicaid do not authorize the Secretary of Health and Human Services to waive provisions of law that proscribe  Medicaid’s basic federal funding structure, for example; nor is there authority that permits the Secretary to grant  exemptions from federal mandates.    Furthermore, pressure to reduce costs  —  rather than to provide healthcare for vulnerable Tennesseans  —  in order to  obtain a kickback from the federal government for a portion of “shared savings” guarantees poor decisions and outright  abuses.  Really, the only ways to squeeze savings out of a barebones system are to cut both services and access to care.     This block grant plan does nothing to address the health problems of a vulnerable population of our state, such as the  shocking number of children who are uninsured, and the economic pressures on our health care system.  Medicaid  expansion could make a substantial difference in that regard, and could benefit Tennessee economically.  I fail to see  why Medicaid expansion is not being pursued, if state government officials are in fact seeking good faith solutions.   Instead, they are developing a plan that does not improve Medicaid but seems calculated to destroy it for the residents  of our state, with real consequences for real people.  For these reasons, and others, I oppose the proposal for block  grant funding.    Very truly yours,    Mary Frances Clark  1690 Kindra Ct.  Brentwood, TN  37027  3 Jonathan Reeve From: Sent: To: Subject: Jarda Tyman Thursday, October 17, 2019 1:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I support mayor Berke.   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Tennesseans need care and coverage, not experiments that will lead to cutting corners in the name of cost-saving.   Jaroslav Tyman.    4 Jonathan Reeve From: Sent: To: Subject: debrastreetkilgore@everyactioncustom.com on behalf of Debra Street Thursday, October 17, 2019 11:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Approving Block Grants is guaranteed to eliminate vital healthcare benefits to those who cannot afford costly healthcare  insurance. Not only does this affect those who are denied access to healthcare but also the many people who interact  with them. A prime example is the recent measles outbreak. By not providing vaccinations, Block Grants insure massive  outbreaks of not only measles but also whooping cough,  the flu, hepatitis, tuberculosis,  bacterial pneumonia to name a  few serious infections and diseases which are easily transmitted. Protect those were who can afford healthcare  insurance and those who cannot by not approving Block Grant's.     Sincerely,  Debra Street  Kingsport, TN 37660  debrastreetkilgore@charter.net  5 Jonathan Reeve From: Sent: To: Subject: Cynthia Parker Thursday, October 17, 2019 10:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant is a Bad Idea     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Hi,    As a taxpayer and mother of an autistic child who relies on various therapies, I’m appalled that our state government is  trying to change the funding of Tenncare in such a detrimental way.     Please listen to the voices of those most affected. This program is for us. We need it.     Thank you,  Cynthia Parker     Sent from my iPhone  6 Jonathan Reeve From: Sent: To: Subject: Vance Sherwood Thursday, October 17, 2019 10:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] block grant comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I want to say the idea behind Block Grant Funding for TennCare is clever.  Everyone can see the system will run  out of money, which means hospitals will end up providing free care through their emergency rooms.  Of  course this will be tough for small hospitals in poorer counties which are stupid enough to provide ER services,  but the larger and better funded hospitals will just have to eat the cost, likely with some help from county  governments.    Thus the Block Grand idea simply relieves the State of covering the poorer children and those who are  disabled, shifting the burden to larger hospitals and maybe county governments.  I do not see how this hurts  Republicans.  The people in the smaller counties will vote for Republican candidates no matter what they do,  and there are not enough disabled folk to swing an election.    Actually it is a Survival of the Fittest approach, where the poorest and weakest are shunted to the side.  I  thought you guys did not believe in evolution, and here you are putting a Darwinian principle into  practice!  Good work!    Vance Sherwood  300 West End Lane  Knoxville, TN 37919  865‐330‐9611  7 Jonathan Reeve From: Sent: To: Subject: Dave Vollrath Thursday, October 17, 2019 9:38 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant for TennCare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the state's request for block grant funding for TennCare.  The proposed block grant would do little or nothing for the hundreds of thousands of state residents not sufficiently  insured. Instead, the proposal seems motivated by the opportunity to reduce ("manage more efficiently") some  coverage and services so that federal dollars can be redirected to other, non‐medical budget items. Overall, the proposal  seems to be an attempt to tap the federal dollars without extending Medicare coverage under the Affordable Care Act.  Dave Vollrath  2101 Christian Ln, Johnson City, TN 37601  8 Jonathan Reeve From: Sent: To: Subject: Deborah Duncan Thursday, October 17, 2019 8:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] MEDICAID BLOCK GRANTS WITH HURT THOSE WITH DOWN SYNDROME   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   As the mother of a teenage son with Down syndrome, I'm greatly concerned about the proposed medicaid  block grants, and I hope that this proposal will NOT go through.    Tennessee’s proposal would include vulnerable eligibility groups such as children and people with disabilities  in the block grant. We have serious concerns about how this will impact their care. Individuals with Down  syndrome face a variety of health concerns, such as congenital heart defects, hearing and vision loss,  respiratory problems, obstructed digestive tracts, childhood leukemia, and other health conditions.  Establishing high‐risk pools, defining sub‐populations and/or setting fixed amounts could be complex,  arbitrary, and detrimental to people with Down syndrome, many of whom would not fit neatly into one  category of complexity or sub‐population.     According to the National Institutes of Health, at least one‐half of all people with Down syndrome also have  co‐occurring conditions that contribute to their medical complexity. For example, approximately half of all  children with Down syndrome are born with congenital heart disease. A person with Down syndrome may also  be defined as a person with a disability, a person with cancer, and a person with Autism, and a person with  Alzheimer’s disease. Proposals that provide for block grants and per capita payment caps, including those that  fund high‐risk pools, must account for the many combinations of complicated health care needs that people  with Down syndrome will face throughout their lifespan.     Additionally, under this proposal, current and future administrations would not need to get approval to make  changes to benefits and services, putting these patients’ care at grave risk. Some examples of this for  individuals with Down syndrome:    Creating longer waiting lists for services    Cutting home and community‐based services and supports that make it possible to live independently and  work in the community    Reducing other critical services such as personal care, mental health, prescription drugs, and rehabilitative  services    Shifting the financial burden for health care, community supports and long‐term services to families and  individuals, many of whom lack financial means to provide these important services     Please take into consideration the critical impact these changes will have on vulnerable populations like those  with Down syndrome. Thank you!    Deborah Duncan  518 Semi Cir.  Chattanooga, TN  37415  (423) 991‐6967   9 Jonathan Reeve From: Sent: To: Subject: msanderson319@everyactioncustom.com on behalf of Michael Sanderson Thursday, October 17, 2019 7:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Michael Sanderson  319 Chesterfield Ave  Nashville, TN 37212‐4020 msanderson319@gmail.com  10 Jonathan Reeve From: Sent: To: Subject: matt_steinhauer@everyactioncustom.com on behalf of Matt Steinhauer Thursday, October 17, 2019 7:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Serious Shortcomings with Block Grant for Tennessee     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    My biggest concern with Block Grants is that it will lead to cuts in benefits for people like my son, Matt, who is  intellectually disabled and on TennCare.      Secondly, I am concerned that those cuts will also impact the people in my community‐‐the poor, and working poor‐‐ who are on Medicaid that often come to the Chruch I pastor to ask for financial assistance with light bills, gas for their  car to get to work, and sometimes rent, and often times food.      I am concerned that there will be cuts that will affect elderly nursing home patients on Medicaid.    When I first heard of the proposal for a Block Grant I visited Republican Leader William Lamberth to ask how Block  Grants would benefit Tennessee.  His response: "For one thing, it would put 700,000 more people on Medicaid. I'm very  aware of how Tennessee's lack of expanding Medicaid has left over 300,000 people uninsured. so I asked where the  extra money would come from to do that? He replied: "Savings in Administrative costs that we have because of the  federal government. I asked him what the administrative budget amount was.  He didn't know.  I have since learned that  Tennessee is one of the top 5 states in administrative efficiency for its Medicaid program, so I'm not sure exactly where  Rep. Lambert thinks those "savings" will come from.    Governor Lee's proposal is very short on detail and contains not a word of how to appeal an issue with Block Grants.    Sincerely,  Matt Steinhauer  100 Yorkshire Ct  Hendersonville, TN 37075‐5836 matt_steinhauer@bellsouth.net  11 Jonathan Reeve From: Sent: To: Subject: Carol Plasil Thursday, October 17, 2019 7:18 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Please do NOT accept this method of funding our medical provision to the poor and disabled in our state.  What our  legislature SHOULD do is Expand Medicaid, which will, by and large , be funded by the Federal government, therefore  giving more people the opportunity for health care.   In the long run, funding better health care means a healthier  population, which will bring a better state for all!  Thank you,  Carol Plasil  12 Jonathan Reeve From: Sent: To: Subject: jcheatha Thursday, October 17, 2019 7:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Against block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  This is not good for Tennessee and not good for Tennesseans. We need MORE health care not LESS. Please remember  better health = a better future for all Tennesseans!     Sent from my iPad  13 Jonathan Reeve From: Sent: To: Cc: Subject: wesley eastridges.com Thursday, October 17, 2019 6:58 AM PUBLICE NOTICE TENNCARE wesley eastridges.com; joy eastridges.com [EXTERNAL] against amendment 42 block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I'd like to argue against amendment 42, the block grant proposal.  While it sounds good to give TennCare freedom to  pursue new ways to efficiently provide healthcare without the restraints other Medicaid systems have, in reality it  results in incentivizing less payments to the actual healthcare providers which results in barriers to people getting care.    Sincerely,   Wesley Eastridge   14 Jonathan Reeve From: Sent: To: Subject: kendra.l.wagener@everyactioncustom.com on behalf of Kendra Wagener Thursday, October 17, 2019 1:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kendra Wagener  1751 Lascassas Pike  Murfreesboro, TN 37130‐2094 kendra.l.wagener@outlook.com  15 Jonathan Reeve From: Sent: To: Subject: malindaferrell2629@everyactioncustom.com on behalf of Malinda Ferrell Thursday, October 17, 2019 2:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against thpe objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Malinda Ferrell  370 Silver Lake Rd  Church Hill, TN 37642‐3540 malindaferrell2629@gmail.com  16 Jonathan Reeve From: Sent: To: Subject: James Taylor Thursday, October 17, 2019 2:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   James Taylor   1904 Long Ave  Nashville, TN 37206   17 Jonathan Reeve From: Sent: To: Subject: James Taylor Thursday, October 17, 2019 2:42 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   James Taylor   1904 Long Ave  Nashville, TN 37206   18 Jonathan Reeve From: Sent: To: Subject: malindaferrell2629@everyactioncustom.com on behalf of Malinda Ferrell Thursday, October 17, 2019 2:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Malinda Ferrell  370 Silver Lake Rd  Church Hill, TN 37642‐3540 malindaferrell2629@gmail.com  19 Jonathan Reeve From: Sent: To: Subject: heatherkay910@everyactioncustom.com on behalf of HEATHER BROWN Thursday, October 17, 2019 6:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    My daughter Natalie came into this world with all of the odds stacked against her. Born at 28 weeks and weighing barely  3 pounds, she was immediately placed on a ventilator and surrounded by countless monitors as well as a myriad of  medical professionals who worked around the clock doing everything in their power to keep her alive. After many tests,  trials, and tears, we were given the heartbreaking news that Natalie will fight every day for the rest of her life. Multiple  diagnoses were hurled at us‐ periventricular leukomalacia, microcephaly, spastic quadriplegic cerebral palsy, cerebral  visual impairment, and lennox‐gastaut syndrome, all of which have cemented our lives in a constant state of preparation  for the worst. Often, I find myself wondering about my child's future. For myself, and many other families in similiar  situations, it is the unknown that causes the most fear and frequent sleepless nights.      Natalie is a medically fragile child. Every aspect of her life has been a whirlwind of appointments, treatments, therapies,  surgeries,and multiple instances of trial and error as her doctors attempt to find the right balance of medications to help  her thrive. Making sure that she has the best possible quality of life has always been a uphill battle, from finding medical  care, home care, to a school that can educate her both mentally and socailly, while having the resources to care for her  medically.     Natalie‐ along with everyone else in this country‐ should have these rights. The rights to have the best quality of life, a  nurturing and safe education, and the right to have proper medical care. This block grant not only opposes these rights ‐  it puts them at risk. It puts her health at risk, and ultimately her life at risk.       The grant supports stopping federal oversight over Tenncare services and other medical expenses. Federal oversight is  vital in making sure that Natalie is not loosing the services and medications she needs simply to live. Federal oversight  ensures families ability to have the right to appeal and a fair hearing if a problem arises. No federal oversight puts  families at risk to loosing these rights to ensure our children get the proper care. The grant supports cost cutting  measures by not paying for some prescriptions. My daughter, in her short 6 years of life, has been on over 17 different  medications ranging from ones that control seizures, to breathing treatments, nutrition supplements ‐ even ones that  relieve her acid reflux. Loosing funding for these medications would be detrimental to her life!       As Natalie's multiple diagnoses dont draw a clear path for her future, there is no way of knowing what is going to  happen or what additional needs we will have to meet. Will she need more medications? Will she need more surgeries?  Will she need more therapies? My daughter has an average life expectancy; What happens as she ages? What new  obstacles will we face?  Will we have the resources to face thoes obstacles? The block grant is one lump sum of money  that would not change for over 3 years. How can Tennessee honestly predict a  specific amount of money that would  cover all of its people? The block grant does not give families the security to ensure that our children will have our their  needs met and be able to succeed. Its definite that medical treatment, services, and medications prices will steadily  increase, all the while the block grant will remain dormant resulting in Tennesseans being refused needed help.      20 I believe the block grant puts the medical needs and future of millions at risk. It would drastically increase the likelihood  of care taker families being financially devastated and unable to have the tools that they need to not only survive, but to  thrive. These are chances, that at the end of the day, we can not, and should not be forced to take. The block grant will  give the state ultimate freedom in an already severely flawed system.  It is a disgraceful proposal of a unethical healthca   Sincerely,  MRS HEATHER BROWN  1207 Lumsley Dr  Lebanon, TN 37087‐1587  heatherkay910@yahoo.com  21 Jonathan Reeve From: Sent: To: Subject: becky.melek11@everyactioncustom.com on behalf of Becky Melek Thursday, October 17, 2019 6:29 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Becky Melek  Antioch, TN 37013  becky.melek11@icloud.com  22 Jonathan Reeve From: Sent: To: Subject: cigisboutique@everyactioncustom.com on behalf of Cigi England Thursday, October 17, 2019 6:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Cigi England  Cookeville, TN 38501  cigisboutique@gmail.com  23 Jonathan Reeve From: Sent: To: Subject: warreng58@everyactioncustom.com on behalf of Grady Warren Thursday, October 17, 2019 6:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Grady Warren  317 May St  Lawrenceburg, TN 38464‐2526  warreng58@yahoo.com  24 Jonathan Reeve From: Sent: To: Subject: Joy Eastridge Thursday, October 17, 2019 6:44 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment re TennCare     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I object to any TennCare (Medicaid) restructuring that would limit the funding for this program. Our less fortunate  children and the poor require our support. It is in our own best interest (long term) to make sure that all children have  appropriate health care. If you limit care now, you will most certainly pay later in the form of long term disability. Please  take the high road and do the right thing for us all. Joy Eastridge, 1233 Radcliffe Ave, Kingsport TN 37664  25 Jonathan Reeve From: Sent: To: Subject: kathythefireescape@everyactioncustom.com on behalf of Kathy Christian Thursday, October 17, 2019 5:52 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    My son‐in‐law has a pacemaker and defibular. He has had back surgery 3 times and totally depends on pu liv health care  to live. My daughter has had a heart attack and she is only 40. My grandson was cut one the first Tncare cut and had to  have an appendectomy while uninsured. That is why I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathy Christian  541 Wilson St  Church Hill, TN 37642‐3531 kathythefireescape@yahoo.com  26 Jonathan Reeve From: Sent: To: Subject: Todd Thursday, October 17, 2019 4:32 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Re: Amendment 42 Comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I do not see how Amendment 42 can be implemented without violating federal law or reducing services for  those served under TennCare. It seems pretty clear that Amendment 42 is asking to waive sections 1903 and  1904 of the Social Security Act. This is something that the state of Tennessee does not have the authority to  do. And neither does the Secretary for Health and Human Services. And considering that the proposal  recommends waiving part of part 1115 but does not even mention part 1903 I have to assume that those who  wrote the proposal are fully aware of this reality. So the State of Tennessee is submitting to violate federal law  in an effort to reduce medical services for those in most need of them. In a state with the highest rates of  medical bankruptcy in the country and one of the highest rates of rural hospital closures in the country. I do  not understand how such an inherently flawed proposal made it out of any competent review process and I  cannot support it in any way.    Baird Todd  2902 Troy Ave  Maryville, TN 37804  27 Jonathan Reeve From: Sent: To: SUE GILREATH Thursday, October 17, 2019 2:00 AM PUBLICE NOTICE TENNCARE     I don’t want the block grant. I have what’s considered complex health issues, managing my health with multiple doctors  is necessary. I’m also on multiple medications. I’m disabled, and I can’t work. I desperately need my Tenncare. If I were  to be cut off of my insurance due to this, my life would suffer greatly. Please think about the people you’re effecting  with these proposals. We’re not just numbers on paper.   28 Jonathan Reeve From: Sent: To: Subject: Carolyn Gibbons Wednesday, October 16, 2019 9:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Federal Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   First of all the State of Tennessee cut many people without their knowledge. That was wrong.  More people will be effected by the Block Grant, they will not get the medical needs from the State of Tennessee.    I vote NO on the Federal Block Grant.    Leave things as they are    Carolyn Camp Gibbons  1620   29 Jonathan Reeve From: Sent: To: Subject: jasonthawk@yahoo.com Wednesday, October 16, 2019 9:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Stop big government   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please stop the nonsense. Stop treating the poor like garbage, while BIG business gets away with destruction.  Tennessee, TNCARE is dysfunctional, don't make it more sloppy like TN STATE GOVERNMENT.  Protect family and STATE  Sent from Yahoo Mail on Android  30 Jonathan Reeve From: Sent: To: Subject: bjt222@everyactioncustom.com on behalf of Bryan Thompson Wednesday, October 16, 2019 5:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I know you have received many of the exact same comments, so I wanted to add my personal words to it. I drove to  Memphis for the Shelby county hearing and 100% of the men and women who spoke voiced their concerns against this  sorry excuse of governing. I believe we are on this earth for the sole purpose of loving one another. This block grant  does not coincide with this belief. In fact, it promotes the neglect of a large number of our brothers and sisters who  need it the most. This grant is simply unfair and unjust. I would like to again state my opposition to this and urge you to  not move forward with this proposal.     Sincerely,  Mr. Bryan Thompson  206 B Elmington Ave  Nashville, TN 37205‐2503 bjt222@gmail.com  31 Jonathan Reeve From: Sent: To: Subject: trose315@everyactioncustom.com on behalf of Teresa Rhodes Wednesday, October 16, 2019 5:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. DO they right thing! Help those that need  help...do them no harm.    Sincerely,  Ms. Teresa Rhodes  Goodlettsville, TN 37072  trose315@comcast.net  32 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of jcrowe13@gmail.com Wednesday, October 16, 2019 5:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Jane Crowe  428 East Springdale Avenue  Knoxville , TN 37917   33 Jonathan Reeve From: Sent: To: Subject: Jill Ryan Wednesday, October 16, 2019 4:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Vote Against Block Grants to Medicaid   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please do not go forward with the Tenncare Block Grant proposal.  It will further decrease access to health care for many  people in our state.  We are in need of better health care and this will not improve things.  We have some of the worst health  outcomes in the country.  Our obestiy levels and opiod abuse levels are not improving to mention just two examples.      Again, please do not approve block grants to medicaid.    Thank you,   Jill Ryan    34 Jonathan Reeve From: Sent: To: Subject: Jim Webster Wednesday, October 16, 2019 3:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Governor Lee has said that a Medicaid block grant would be “a great deal for Tennessee, a  great deal for TennCare.” He has said that opposition to the block grant stems from a lack of  understanding of the details of the program. That is Balderdash!    That’s the problem. This hearing is a one‐way communication effort. It’s not two‐way, and it’s  not designed to answer our questions and concerns this afternoon.    We want a non‐partisan review of the expected outcomes, challenges, and problems before  proceeding. No other state has taken this road before Tennessee, so we will be the guinea  pigs. The reasons for changing the payment format are not at all clear. How the block grant  approach will improve the health of our citizens is not at all clear. How TennCare would be  made more efficient by receiving a block grant is not clear. How we can cover those in the GAP  is not clear.What will be our exit strategy when the block grant approach proves to be a  failure?    The Governor’s Healthcare Modernization Task Force has only just been formed and, as far as I  know, has yet to meet. The purported goal for this committee is to develop recommendations  for improving the health of Tennesseans. Common sense would indicate that their report  should be received and studied before proceeding with a waiver request for a block grant.    Tennessee is one of the most unhealthy states in the country. We lead the country in medical‐ related personal bankruptcies. Tennessee and Texas lead the country in the number of  hospital closings in rural areas. We don’t need to be heading out into the wilderness on  healthcare. We need to implement actually‐effective strategies to improve the health of our  citizens, and these strategies need to have the support of the health care providers, receivers,  and the citizens. These are matters with life and death consequences.    If anyone in Governor Lee’s administration is paying attention to our comments, tell them we  don’t want a block grant. We want Medicaid Expansion!      Jim Webster, CTS‐D, ISF‐C  35 Continental Film  P.O. Box 5126  1466 Riverside Drive  Chattanooga, TN 37406  Tel: 423‐622‐1193  Fax: 423‐629‐0853  www.continentalfilm.com  jim.webster@continentalfilm.com     36 Jonathan Reeve From: Sent: To: Subject: tptuley@everyactioncustom.com on behalf of Therese Tuley Wednesday, October 16, 2019 3:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Therese Tuley  1005 E Dallas Rd  Chattanooga, TN 37405‐2208 tptuley@gmail.com  37 Jonathan Reeve From: Sent: To: Subject: Ellen Gennaro Wednesday, October 16, 2019 2:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] NO to Tenn Care Ammendment 42     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Representative Jim Cooper says it far better and more comprehensively than I can:    https://urldefense.com/v3/__https://cooper.house.gov/media‐center/press‐releases/cooper‐testifies‐at‐middle‐ tennessee‐tenncare‐block‐grant‐ hearing__;!dyXff_z6q0o!5ZSiZH8vdZCiHb93ykwcOoSz6cV1wNJMvqXfLD_4pwNuGsz9LcvJRXxMZtA‐GRXeGgfsyJdQJA$     Ellen Gennaro      38 Jonathan Reeve From: Sent: To: Subject: Tony Campbell Wednesday, October 16, 2019 2:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Monday, October 14, 2019    Protect Mental Health Services Meeting  Chattanooga, Tennessee   Wednesday October 16, 2019  Topic Of Concern: Amendment 42 Tennessee "Block Grant" for Tenn Care.    Hello, My name is Tony Campbell, I have a lived diagnosis and am a peer consumer. I currently receive Medicare and  Tenncare for my health care coverage. I have been a NAMI Tennessee member in the past.  I come before you today with a few concerns. I receive my services through a health plan. Right now, federal regulations  protect my ability access to services, ensuring that plans have enough mental professionals, and give me the ability to  appeal denials of services.   This Block Grant Proposal would REMOVE these protections and open the way for heath plans to cut payments to  providers ‐ making it more difficult for myself and others to get services and report that to anyone.  Also, the state's proposal would limit access to prescription drugs for beneficiaries who need them by excluding high‐ cost drugs from coverage. This would shift the cost of these drugs onto the beneficiaries who need them but can‐not  afford to pay for them.  I would like to thank you for your time and attention to this serious matter that would effect many peer consumers like  myself across the state of Tennessee. At this time I would like to submit this for the record.  Tony Campbell  (423) 364‐8711  Chattanoogatazz@gmail.com  PO Box 8756  Chattanooga, TN 37414  Consumer of Services & Peer Advocate  39 Jonathan Reeve From: Sent: To: Subject: Stephanie Marion Wednesday, October 16, 2019 1:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] No to Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Please do not go through with TennCare block grant proposal.      Thank You,    Stephanie Marion  smarion123@me.com      Sent from my iPhone  40 Jonathan Reeve From: Sent: To: Subject: jwrcupp@everyactioncustom.com on behalf of William James Wednesday, October 16, 2019 12:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  William James  Kingsport, TN 37660  jwrcupp@yahoo.com  41 Jonathan Reeve From: Sent: To: Subject: lachana316@everyactioncustom.com on behalf of Ellen Nelson Wednesday, October 16, 2019 1:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TN Block GrantComment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the radical proposal to change Medicaid to a program with Tennessee politicians dictating the use of  the funds.  Federal requirements are stringent about allowable uses of funds and less subject to local political whims.    Medicaid is supposed to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Tennessee politicians Have already turned down billions of federal dollars To improve coverage or needy populations.  This has resulted in the closure of several rural hospitals, Striking not. only the financially vulnerableBut also each and  every resident who  relied on those local hospitals    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Tennessee politicians have already shown us that they are too reckless and irresponsible to be trusted with the control  of Medicaid.    Sincerely,  Ellen Nelson  1410 Nichol Creek Dr  Jamestown, TN 38556‐1018 lachana316@aol.com  42 Jonathan Reeve From: Sent: To: Subject: carlgwagner@everyactioncustom.com on behalf of Carl Wagner Wednesday, October 16, 2019 6:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block-granting Medicaid to   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Carl Wagner  1324 Beacon Hill Ln  Knoxville, TN 37919‐7652 carlgwagner@gmail.com  43 Jonathan Reeve From: Sent: To: Subject: carlgwagner@everyactioncustom.com on behalf of Carl Wagner Wednesday, October 16, 2019 6:58 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Carl Wagner  1324 Beacon Hill Ln  Knoxville, TN 37919‐7652 carlgwagner@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: rjorg.c@everyactioncustom.com on behalf of Rachel Jorgensen Wednesday, October 16, 2019 7:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rachel Jorgensen  Chattanooga, TN 37405  rjorg.c@gmail.com  45 Jonathan Reeve From: Sent: To: Subject: freyamind@everyactioncustom.com on behalf of Nancy Wight Wednesday, October 16, 2019 7:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Nancy Wight  3721 Stonetrace Cir  Bartlett, TN 38135‐3092 freyamind@yahoo.com  46 Jonathan Reeve From: Sent: To: Subject: kvgorden@everyactioncustom.com on behalf of Kerisa Shorthouse Wednesday, October 16, 2019 7:44 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I am not a middle or upper class American. I work part‐time, and my husband works through a temp agency. If we were  to have a child (which is our goal within the year), Tenncare would likely be the only insurance option for my prenatal  care and my baby's childhood medical needs. I believe in vaccines and health screenings, and you want me to tackle  those expensive tests with less assistance? Not to mention the cost of getting sick or broken bones outside of regular  check‐ups!    In addition, I have a friend on disability who can barely afford food and housing through SSI, much less activities and  items that contribute to a meaningful, enjoyable life. Her monthly financial "pension" isn't enough to get someone like  me through two weeks of living expenses. And you want to cut it even more?    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients. This  proposal invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I‐‐and all of us who rely on Medicaid for our daily needs‐‐respectfully urge you not to go forward with this harmful  proposal.    Sincerely,  Mrs. Kerisa Shorthouse  Cleveland, TN 37311  kvgorden@gmail.com  47 Jonathan Reeve From: Sent: To: Subject: bard.song45@everyactioncustom.com on behalf of Courtney McDonald Wednesday, October 16, 2019 7:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     My sister has multiple serious health conditions (one of which is horrendous seizures that put her out of commission for  days) and she relies on TennCare for the doctors and specialists she has to see on a regular basis as well as for the  cocktail of medications she has to take to control her symptoms. She would not be able to afford her care without  Medicaid. Even new restrictions to Medicaid, like limiting the already limited number of prescriptions covered even  more or removing some doctors from network could severely impact her health and quality of life.    We need to be ensuring that the most vulnerable populations are able to get the treatment they need. Without it many  will suffer and could even die. We should be expanding Medicaid to cover more people not reforming it to cover less. It  was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get vital health  coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to  cut services for these vulnerable populations. The state could eliminate or restrict services like physical therapy, hospice,  and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The proposal could also  cut back on core health care services like hospital care, without federal approval or public notice, and exclude coverage  of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Courtney McDonald  Chattanooga, TN 37416  bard.song45@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: kgray510@everyactioncustom.com on behalf of Kay Gray Wednesday, October 16, 2019 8:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose Medicaid Block Grant Proposal   Dear Gabe Roberts,    Being a person with many privileges it would be easy to ignore this proposal of a Block Grant.  However, it is clear our  culture has settled in this mindset of self‐centered concern.  It is awful to think of folks in rural communities with their  hospitals closed or their critical health needs not covered because they are “ invisible” to the powerful.    Please do NOT permit this Medicaid Block Grant out of the arrogant perspective that we are too all‐knowing to find  federal regulations unnecessary.  In every aspect of life we need accountability.    The more privileged we are the more we need help to increase our awareness of the vulnerable.    Thanks for hearing me out!    Sincerely,    Kay Gray    Sincerely,  Dr. Kay Gray  2923 Windemere Cir  Nashville, TN 37214‐1611 kgray510@gmail.com  49 Jonathan Reeve From: Sent: To: Subject: BARTON MARGOSHES Wednesday, October 16, 2019 9:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   BARTON MARGOSHES   298 Dudala Pl  Loudon, TN 37774   50 Jonathan Reeve From: Sent: To: Subject: Kathleen Porcello Wednesday, October 16, 2019 10:35 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Kathleen Porcello   146 Noya Way  Loudon, TN 37774   51 Jonathan Reeve From: Sent: To: Subject: davisdentons@everyactioncustom.com on behalf of Alona Burnett Wednesday, October 16, 2019 11:02 AM PUBLICE NOTICE TENNCARE [EXTERNAL] The PEOPLE OF THIS STATE ARE WORTHY OF AFFORDABLE HEALTHCARE. THOSE WHO ARE WEALTHY IN THIS STATE WERE MADE SO BY THESE PEOPLE!!! IT IS THE RESPONSIBILITY OF THE WEALTHY TO HELP NOT HINDER THOSE WHO ARE MOST VULomment Opposing Medicaid Block...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Alona Burnett  Memphis, TN 38117  davisdentons@yahoo.com  52 Jonathan Reeve From: Sent: To: Subject: nicolexxx189@everyactioncustom.com on behalf of Desiree Smith Wednesday, October 16, 2019 11:09 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Desiree Smith  104 Landcastle Rd  Church Hill, TN 37642‐6024 nicolexxx189@gmail.com  53 Jonathan Reeve From: Sent: To: Subject: ttwhitman14@everyactioncustom.com on behalf of Teresa Whitman Wednesday, October 16, 2019 11:20 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Teresa Whitman  349 Shadowtown Rd  Blountville, TN 37617‐4343 ttwhitman14@gmail.com  54 Jonathan Reeve From: Sent: To: Subject: charlottelight@everyactioncustom.com on behalf of Charlotte Light Wednesday, October 16, 2019 11:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Charlotte Light  2602 Halifax Dr  Kingsport, TN 37660‐2393 charlottelight@chartertn.net  55 Jonathan Reeve From: Sent: To: Subject: desiegentry@everyactioncustom.com on behalf of Desie Gentry Wednesday, October 16, 2019 11:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Desie Gentry  110 Corn Maze Ln  Elizabethton, TN 37643‐5476 desiegentry@gmail.com  56 Jonathan Reeve From: Sent: To: Subject: nancyllaws@everyactioncustom.com on behalf of Nancy Laws Wednesday, October 16, 2019 11:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Nancy Laws  240 Deerwood Rd  Greeneville, TN 37743‐5839 nancyllaws@gmail.com  57 Jonathan Reeve From: Sent: To: Subject: briness2011@everyactioncustom.com on behalf of Brittney Riness Wednesday, October 16, 2019 11:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Brittney Riness  Bristol, TN 37620  briness2011@aol.com  58 Jonathan Reeve From: Sent: To: Subject: David N. Orth Wednesday, October 16, 2019 12:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Sir/Madam:    As a retired physician, Emeritus Professor of Medicine at Vanderbilt, patient, and Tennessean, I write to express my  grave misgivings about TennCare's block grant proposal to the federal government next month.    If our state government wanted to assist the unconscionably large number of citizens who have little or no access to  adequate health care, it should have done so years ago by expanding Medicaid as provided for by the Affordable Care  Act.  We have forfeited billions of dollars in Tennessee taxpayers' money in failing to do so, strictly on the basis of  politics.  Governor Haslam attempted to negotiate with the federal government to do something to address this  problem, but even he, a Republican governor, was unable to convince the supermajority of rural conservatives that  constitute the Tennessee legislature to act responsibly.    The current governor's block grant concept is based on the notion that the state government can do better than Centers  for Medicare and Medicaid Services guidelines in providing health care for its neediest citizens.  The State of Tennessee  has a very poor record with regard to doing better than the federal government at almost anything, certainly in  providing for the health of its citizens. Tennessee ranks at or near the bottom of the fifty states in virtually every single  measure of health.  It is an embarrassment that should be felt by every person involved in any way in health care in our  state, felt as an outrage by those who have been so poorly served by our state government, and felt as a source of  shame for every Tennesseean.    Governor Lee's actual motive for the grant is to "save" money that will be shared by the federal government and the  Tennessee government, which the state may use to provide additional unnamed services to TennCare  subscribers.  There is no indication of the source of these savings, but the overwhelming prospect is by limiting the  number of persons covered and the services that they are provided.  How the "savings" would actually be used is equally  unspecified.    This proposal is nothing more or less than another attempt by a state government run by representatives who deny its  responsibility to provide reasonable access to basic health care to its neediest citizens, just as their equally misguided  enthusiasm for school vouchers is a denial of their responsibility to provide equal access to quality education to all of our  children in public schools.    I find no merit in this proposal and sincerely hope the Centers for Medicare and Medicaid Services will reject the  application.    Thank you for your attention to my concerns.    Sincerely,    David N. Orth, M.D.  Professor Emeritus of Medicine, Molecular Physiology & Biophysics, Vanderbilt University Medical Center  59 5808 Beauregard Drive, Nashville, TN 37215‐4805        60 Jonathan Reeve From: Sent: To: Subject: Janet Reed Wednesday, October 16, 2019 12:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Janet Reed   331 Agoli Ln  Loudon, TN 37774   61 Jonathan Reeve From: Sent: To: Subject: crystal.moore154@everyactioncustom.com on behalf of Crystal Moore Wednesday, October 16, 2019 11:06 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Crystal Moore  Kingsport, TN 37663  crystal.moore154@gmail.com  62 Jonathan Reeve From: Sent: To: Subject: jlcarroll@everyactioncustom.com on behalf of Janet Carroll Wednesday, October 16, 2019 10:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Janet Carroll  Linden, TN 37096  jlcarroll@live.com  63 Jonathan Reeve From: Sent: To: Subject: edward brandon Wednesday, October 16, 2019 10:23 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   edward brandon   136 Coyatee Cir  Loudon, TN 37774   64 Jonathan Reeve From: Sent: To: Subject: lhenighan@everyactioncustom.com on behalf of Lucy Henighan Wednesday, October 16, 2019 10:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant. I basically don’t trust Tennessee to protect our vulnerable people.  There is a lot of talk about “saving money” and being “more efficient” but no specifics about how that would come  about. I am afraid it could mean unapproved drugs, elimination of services like physical therapy or transportation or  something else vital. I think we NEED oversight not it’s elimination. In addition the plan does not indicate what this  windfall of savings would be spent on. It is very hard to have confidence in a plan devised by the Tennessee government,  the very government that wouldn’t expand Medicaid which would have definitely helped citizens as well as hospitals.    Sincerely,    Lucy Henighan  Seymour, Tennessee        Sincerely,  Lucy Henighan  619 Mountain View Dr  Seymour, TN 37865‐4323 lhenighan@gmail.com  65 Jonathan Reeve From: Sent: To: Subject: Diane Cambron Wednesday, October 16, 2019 10:09 AM PUBLICE NOTICE TENNCARE [EXTERNAL] ADMINISTRATION OF TENNCARE BLOCK GRANT   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I attended the public hearing in Memphis regarding the administration of the new federal block grant for  Medicaid costs under Tenncare.    I have grave concerns about the very fact of the block grant itself, but as I understand it, the law has already  been enacted, so there is little to be done at this point, except wait for the inevitable legal challenges.    With regard to the block grant funds, it is my understanding that the main purpose of the block grant funding  method is to eliminate federal oversight and to give Tennessee benefit of the savings to be derived  therefrom.  That being the case, I am not sure that there are enough guarantees in the plan to prevent the  further closure of rural hospitals, or to prevent basic rights from being denied to certain populations based  upon the whims of whatever administration happens to be in office.    There should be strong wording in the plan to guarantee that ANY savings derived from the program MUST be  used to increase Medicaid enrollment for members of the working poor as was envisioned under the ACA; to  close gaps in existing coverage to our most vulnerable citizens, particularly the disabled and chronically ill; to  streamline the process for navigating the system; to increase the number of physicians that serve Medicaid  enrollees; and to guarantee Medicaid enrolled women access to birth control and other women's healthcare  services.    With somewhere between 200,000 and 300,000 uninsured Tennesseans, and with numerous counties having  suffered the loss of local hospitals, it would be unconscionable for savings derived from this program to be  used for any other purpose than to plow back into additional health care benefits for Tennesseans in  crisis.  Failure to have access to health care creates financial and emotional stress on families and  communities, and we as a state should be ashamed of our record.      Thank you for your consideration.      Diane Cambron  404 Reksten Cove  Cordova, TN 38018  901‐351‐7389      66 Jonathan Reeve From: Sent: To: Subject: Amy or Steve Mulroy Wednesday, October 16, 2019 9:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom it May ConcernI am a Tennessee resident who is adamantly opposed to having a block grant to support our Medicaid program. The plan contains too few details about how our residents in need will be adequately cared for. In fact, the Legislature's stated goal for the switch to a block grant is to save money, and savings can only come from cutting enrollment, cutting services to those enrolled, or cutting payment to providers, which will result in even fewer participating providers. The sole purpose of TennCare is to provide healthcare for the poorest residents of Tennessee. Please tell the legislators that TennCare will not support this ill-advised, racist plan to save money. Rather, you should demand that the Legislature expand Medicaid so that you can adequately fulfill your mission. Amy Mulroy 1035 Perkins Terrace Memphis, TN 38117 901-766-0902 67 Jonathan Reeve From: Sent: To: Subject: Sandy McCrea Wednesday, October 16, 2019 9:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment on Block Grant for TennCare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the proposed Block Grant system for funding TennCare in Tennessee. Facts: 1. According to the US Census Bureau, in 2018, Tennessee had the third largest increase in uninsured citizens with the number rising by 46,000. That means that 675,000 Tennesseans (1 in 10) are without any insurance. The number of uninsured children in TN is the highest in 5 years, with those numbers rising rapidly in in 2017 (33% increase) and 2018 (17% increase). Over a two-year period, Tennessee dropped 128,000 children from its TennCare rolls due to outdated processing methods. 2. Tennessee ranks 10th in the nation for medical debt of its citizens. In 38 of Tennessee’s 95 counties, 25-30% of the population has medical debt. This is due, at least in part, to the lack of health care coverage. 3. Tennessee’s failure to expand Medicaid has increased health risks for the most vulnerable Tennesseans, increased health care cost for all, while foregoing millions of dollars Tennesseans have paid in taxes to the federal government that could be returned to Tennessee to cover uninsured Tennesseans. Tennessee will lose and estimated 26 billion dollars over the next decade. Clearly, Tennessee has a serious health care problem. A system of block grant funding does nothing to address that problem and will only make matters worse. 1. The block grant will NOT expand coverage to the over 300,000 poor without children. Many of these people work but do not earn enough to qualify for federally subsidized coverage on the exchange. 2. The block grant removes Tennessee from federal oversight and gives it discretion over: (a) The enrollment and eligibility process; (b) Certain coverage determinations; (c) The rules for managed care, including rules for access and determining the adequacy of the care provided; (d) All decisions on management of the system including management of enrollment and coverage. 3. Further, the state will be exempt from any new rules concerning the administration of Medicaid, which could include any new rules restricting the denial of coverage based upon civil rights violations. Given that, in 2016, Tennessee attempted to circumvent the Medicaid fair hearing regulations imposed by the federal government [Wilson v. Gordon], and that it negligently purged of 128,00 children from the TennCare rolls, there is little reason to believe that Tennessee will fairly and adequately administer a TennCare program lacking in federal oversight and the ability to bring federal law to bear on Tennessee administrators. Equally significant is the fact that the block grant will allow Tennessee to retain 50% of any saving incurred in a year. Thus, TN could cut enrollment to generate savings, which can then be put to other uses not specifically directed at health care for enrollees. This is a risky provision, given recent events suggesting that our legislature is more concerned with the budget than with the health of Tennessee’s children and working poor. Finally, because the base years for determining the amount of funding provided are 2016-2018, it is likely the grant will start out being underfunded. This is because we know those years include a period when large numbers of otherwise eligible children and adults were incorrectly purged from the TennCare rolls. A block grant for funding health care coverage for Tennessee’s poorest and most vulnerable population is A VERY BAD IDEA and I strongly oppose it. Sandra K. McCrea 1058 Whippoorwill Drive Signal Mountain, TN 37377 (423) 800-3086   68 Jonathan Reeve From: Sent: To: Subject: Jeanne Marchetti Wednesday, October 16, 2019 9:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.  On a personal note, the life expectancy for my 33 year old daughter was 12 when I was in Nursing school at Vanderbilt.  Now that life expectancy is 40. Margaret’s health is an issue but she now has a loving husband and a Teo year old named  Betty. She needs the most current drugs prescribed by her CF pulmonary doctors. I shudder to think of a formulary  which might prevent Margaret from receiving those drugs. Margaret’s life would be gravely impacted. Please don’t vote  for this block grant. At this time, the affordable care act is the best option for her and others with chronic illness.  Thank you for taking the time to read this email.    Sincerely,   Jeanne Marchetti   4300 Warner Pl  Nashville, TN 37205   69 Jonathan Reeve From: Sent: To: Subject: bw423@everyactioncustom.com on behalf of Brandi Wells Tuesday, October 15, 2019 7:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     My family relies on TennCare for our healthcare needs. I do not have access to health insurance from my employer. I do  not earn enough to seek out health insurance from private providers or the Market Place. My son was recently dropped  from the TennCare program because he is 19 although TennCare does allow coverage until the age of 21. My son had a  medical emergency at the age of 11 and thankfully TennCare provided the needed surgery and aftercare for him. We  were sent to 3 specialists between Tennessee and North Carolina and a "block grant" that is proposed could have had  devastating effects on his health in limiting his care.  My son is now healthy but still needs yearly MRIs to watch his brain tumor and ensure it does not grow. Any lapse in his  coverage puts him in a situation to not receive medical care her needs.     TennCare needs more accountability, not less. We are now in an appeal process to reinstate his coverage. Hopefully we  will not have an emergency in the mean time. My son is an outstanding student and athlete and he deserves to have  healthcare that is not threatened by block grants that would otherwise help fund the costs of his care.    As another citizen has said: "The state should not be allowed to make changes to the Medicaid program without federal  oversight or eliminate federal standards, which are in place for the protection of patients. Without such guardrails, the  state could return to the days when managed care contractors failed to provide care to patients and providers were left  unpaid. This proposal invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans."   We are a working family and contribute in everyday possible, but we do need help with healthcare. A young adult  starting out in college should not have to worry about coverage and medical costs or lack of care for his condition. The  children and young adults are our future and it is up to us to give the them best start possible. TennCare is already hard  to apply for and keep coverage and find providers that take it. We do not need "block grants" that will further hinder  care for our most vulnerable.    "This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid  program. We respectfully urge you not to go forward with this harmful proposal."    Sincerely,  Brandi Wells    Sincerely,  Brandi Wells  Johnson City, TN 37604  bw423@charter.net  70 Jonathan Reeve From: Sent: To: Subject: beth.brown4395@everyactioncustom.com on behalf of Cora Brown Tuesday, October 15, 2019 8:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Cora Brown  Mount Carmel, TN 37645  beth.brown4395@gmail.com  71 Jonathan Reeve From: Sent: To: Subject: nursemarajean@everyactioncustom.com on behalf of Mara Gonzales Tuesday, October 15, 2019 8:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I live in California. The one thing I can say about California is that they have a wonderful medical program {what you call  Medicaid}. This has made it possible for my best friends child who has a chromosomal disorder be able to receive all the  therapies and doctors visits and supplies she needs. My heart hurts when I read about what Tennessee wants to do with  their program.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I would not say this in any other way, but in this aspect, Tennessee be more like California.     Sincerely,  Mara Gonzales  1675 Delaware Ave  Tulare, CA 93274‐9221 nursemarajean@gmail.com  72 Jonathan Reeve From: Sent: To: Subject: ashleystreet80@everyactioncustom.com on behalf of Ashley Street Miller Tuesday, October 15, 2019 8:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ashley Street Miller  Johnson City, TN 37604  ashleystreet80@gmail.com  73 Jonathan Reeve From: Sent: To: Subject: fbednarek63@everyactioncustom.com on behalf of Faith Bednarek Tuesday, October 15, 2019 8:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposed to Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make more changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients and  should be enforced. Without such guardrails, the state could return to the days when managed care contractors failed to  provide care to patients and providers were left unpaid. This proposal invites more fraud and abuse and threatens the  availability of vital health coverage for Tennesseans. As a victim of receiving poor care, abuse at the hands of a physician,  falsified medical records and a recipient of TennCare this problem cannot be allowed to worsen.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Faith Bednarek  5390 Loch Lomond Rd  Memphis, TN 38116‐9049 fbednarek63@gmail.com  74 Jonathan Reeve From: Sent: To: Subject: tangelam29@everyactioncustom.com on behalf of April M Tuesday, October 15, 2019 8:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. April M  Arlington, TN 38002  tangelam29@gmail.com  75 Jonathan Reeve From: Sent: To: Subject: christinaEMason@everyactioncustom.com on behalf of Christina Mason Tuesday, October 15, 2019 8:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Stop the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I and my extended family, who reside in Sevier County, strongly oppose the proposal to convert federal funding for  TennCare into a “block grant.”  In our experience TennCare needs more oversight and accountability and more access  and funding for residents, not less. The proposed change would cause immense harm and jeopardize coverage for  vulnerable TennCare recipients such as my 86‐year old grandmother, Joan Mehailescu.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. It is  already extraordinarily difficult to get approval for TennCare, even for an elderly person like my grandmother who has  dementia and Alzheimers, a fixed income, and who needs help with all her Activities of Daily Life (ADLs). It took our  family two lawyers and help from least two TN non‐profits to cut through all the red tape and barriers already in place to keep people off TennCare.    There already isn't enough funding to go around. The proposal could also cut back on core health care services like  hospital care, without federal approval or public notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.  The risk is too great ‐ my grandmother's health and safety are is at stake. Don't do  this.    This waiver goes against the goals and purpose of the Medicaid program. I urge you not to go forward with this harmful  proposal.  Joan Mehailescu deserves better. Tennesseans deserve better.    Sincerely,  Christina Mason  217 Brucemont Cir  Asheville, NC 28806‐0190 christinaEMason@gmail.com  76 Jonathan Reeve From: Sent: To: Subject: joycesusanmason@everyactioncustom.com on behalf of Joyce Sipma Tuesday, October 15, 2019 8:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] We oppose Medicaid Block Grant Proposal   Dear Gabe Roberts,    My husband and I oppose the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans. My mother, Joan Mehailescu, who is only alive thanks to TennCare  services, is one whose health would be gravely at risk if this were to pass.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joyce Sipma  4014 Hitching Post Rd  Pigeon Forge, TN 37863‐3632 joycesusanmason@gmail.com  77 Jonathan Reeve From: Sent: To: Subject: lmerriman8922@everyactioncustom.com on behalf of Leesa Merriman Tuesday, October 15, 2019 8:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a deacon of a church that gets frequent calls for help from members of the community who are on TennCare or  Medicaid or should be because of their life situations. These are people who don’t have their own transportation and  have difficulty getting to the only resources that are available to them. They may need help with mental health  problems. Some need counseling for emotional issues. Some of them are unable to work because of illness or disability,  yet the medical help they need is not covered by TennCare. This might include glasses, prescriptions, doctors,  chiropractors, dentists, certain clinics that could help with specific issues. I understand there is only so much tax money  to go around, but surely the state is better served if the vulnerable and sick are able to get as healthy as possible. Some  might even be able to return to work and pay taxes.   Thank you  Leesa Merriman     Sincerely,  Leesa Merriman  Chattanooga, TN 37412  lmerriman8922@gmail.com  78 Jonathan Reeve From: Sent: To: Subject: court_200826@everyactioncustom.com on behalf of Courtney Hargis Tuesday, October 15, 2019 9:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Courtney Hargis  4481 Pippin Rd  Cookeville, TN 38501‐7817 court_200826@yahoo.com  79 Jonathan Reeve From: Sent: To: Subject: helenbuckleylsw@everyactioncustom.com on behalf of Helen Buckley Tuesday, October 15, 2019 9:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Helen Buckley  6574 E Brainerd Rd Apt 810 Chattanooga, TN 37421‐3708 helenbuckleylsw@yahoo.com  80 Jonathan Reeve From: Sent: To: Subject: haleyandian@everyactioncustom.com on behalf of Haley Nail Tuesday, October 15, 2019 9:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Request to Oppose TennCare Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     This proposal would limit funds in a state that already underperforms on numerous health measures. It would allow the  state freedom from federal oversight on determining required and optional coverage, access and network adequacy  protections, eligibility requirements, and other coverage, enrollment, or management decisions. The cap would be  adjusted according to annual growth estimates rather than changes in costs even though healthcare costs are rising  faster than inflation. This presents the Tennessee public with the threat of slashed coverages and protections. These  changes undermine the entire purpose of Tennessee's Medicaid program, which is to ensure necessary medical care for  the citizens of Tennessee, especially the most vulnerable.     TennCare has been incredibly important to me and my family. I have heart disease that requires medications and  expensive yearly care. Since my husband's job did not provide family health insurance, I remained under my father's  health insurance for a few years. My father's insurance had a $5,000 out of pocket cost limit for each individual on the  plan. Thus, my husband and I were charged thousands of dollars in medical bills every year.   One year, my cardiac care had cost us $5,000 already by the end of March. Then we found out we were pregnant, with  twins! I was already considered a high‐risk pregnancy, but carrying twins increased those risks even more. I saw a high  risk specialist every month and had ultrasounds twice a month, then every week, then twice a week as the pregnancy  progressed. The babies also had to get special tests done in utero.  Having already spent our out of pocket costs for the year, my pregnancy care would be covered for the first 6 months of  the pregnancy. But, once January hit, we knew we would be paying $5,000 each for all three of us, if my children were  even qualified on my father's plan. Then, my dad took a job with a different company, leaving me to scramble to figure  out what we were going to do. We would have to start over completely on our out‐of‐pocket costs for the year and then  pay out of pocket again starting in January. In the course of 12 months time, we would have likely accumulated $25,000  of medical bills, and we were still paying on thousands of dollars from previous years.   Instead, I looked into TennCare. I was able to get enrolled quickly, and once the babies were born they got enrolled as  well. As we cannot afford full time daycare for two children, I am not able to work a normal full‐time job anymore. My  husband also works part‐time as he is pursuing his bachelor's degree. TennCare enables me and my children to get the  medical care we need. Even more, it allows our family to move forward toward better careers and financial  independence. If funds were cut and accountability was removed from the program, this would harm many families,  including my own.   Tennessee has already refused the ACA expansion. The state caps eligibility for parents at 95% the federal poverty level  and offers no coverage for non disabled working‐age adults without minor children. This leaves hundreds of thousands  of adults in Tennessee uninsured. TennCare has also been cutting children out of the program, even those who are still  eligible. This block grant proposal would further decrease health insurance and medical care for the state's most  vulnerable populations. I believe that this proposal should absolutely not be an approved change for a program whose  goal is to provide medical assistance to American citizens.    81 This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Haley Nail  743 Chestnut Ave  Cookeville, TN 38501‐1658 haleyandian@gmail.com  82 Jonathan Reeve From: Sent: To: Subject: bryannashelby@everyactioncustom.com on behalf of Bryanna Shelby Tuesday, October 15, 2019 9:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Bryanna Shelby  Bluff City, TN 37618  bryannashelby@yahoo.com  83 Jonathan Reeve From: Sent: To: Subject: tangelam29@everyactioncustom.com on behalf of april M Tuesday, October 15, 2019 10:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a single mom with a disability, and Medicaid makes our family stronger. It allows my son to get the check ups he  needs to go to school, and it allows me to get the care I need to be the best mother I can be.    Block Grants destabilize our Medicaid program putting our health care at risk. Without access to affordable care,  families like mine get sicker and die quicker.     Our government is supposed to be of the people, for the people. We are supposed to stand united. Yet, there are  millions of uninsured Americans while our elected officials get free health care for life. If the tables were turned and it  was your family’s health care, would you still put Medicaid’s future at risk?     Please do the right thing ‐ the moral thing. Don’t take away our health care. Don’t jeopardize our health. Don’t block  grant Medicaid.    God Bless    Sincerely,  Ms. april M  Lakeland, TN 38002  tangelam29@gmail.com  84 Jonathan Reeve From: Sent: To: Subject: ashammock@everyactioncustom.com on behalf of Aja Hutchins Tuesday, October 15, 2019 11:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Aja Hutchins  Piney Flats, TN 37686  ashammock@gmail.com  85 Jonathan Reeve From: Sent: To: Subject: LYLedbetter@everyactioncustom.com on behalf of Louise Ledbetter Wednesday, October 16, 2019 2:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a physician in rural middle Tennessee, and I have been treating treating patients with TennCare since January 1,  1994.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.”     This proposal would cause immense harm and jeopardize coverage for the most vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need.     This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these  vulnerable populations. The state could eliminate or restrict medical services.    The state should not be allowed to make changes to the Medicaid program without federal oversight or eliminate  federal standards, which are in place for the protection of patients. This proposal invites fraud and abuse and threatens  the availability of vital health coverage for Tennesseans.     I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Louise Ledbetter  Columbia, TN 38401  LYLedbetter@gmail.com  87 Jonathan Reeve From: Sent: To: Subject: amlowrey01@everyactioncustom.com on behalf of Angela Lowrey Wednesday, October 16, 2019 5:04 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Angela Lowrey  Memphis, TN 38108  amlowrey01@gmail.com  88 Jonathan Reeve From: Sent: To: Subject: Debby Gould Wednesday, October 16, 2019 9:08 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Public response to Block Grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Amendment 42 is a proposal to change the funding formula for TennCare to a block grant. There are many flaws in this proposal that will result in worsened health outcomes for the Tennesseans who need these resources.There is no element of this proposal that addresses the unmet health needs of the 300,000 uninsured Tennesseans.    The proposal has no mechanism for federal accountability of how funds are spent. The cost savings for standardized formularies will mean adverse outcomes for individuals that do not respond well to the limited range of prescriptions available. There is no element of this proposal that addresses the unmet health needs of the 300,000 uninsured Tennesseans. Debby Gould  1817 Beechwood Ave  Nashville, TN 37212  89 Jonathan Reeve From: Sent: To: Subject: Anne Carlisle Wednesday, October 16, 2019 7:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Tennessee needs to make health care accessible for all its residents, including the low income and marginalized  population.     I am opposed to the block grant proposal for TennCare, which would reduce access to medical care for our neediest  population.     I am embarrassed by my state's abandonment of its lower income citizens.    Anne Carlisle  90 Jonathan Reeve From: Sent: To: Subject: T E FLACH Wednesday, October 16, 2019 7:35 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Since this is not being put to a vote among citizens, I would like to register my opinion AGAINST this idea of Medicaid Block Grants. NO TO BLOCK GRANTS 91 Jonathan Reeve From: Sent: To: Subject: pelaynep@everyactioncustom.com on behalf of P Elayne Poston Wednesday, October 16, 2019 5:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Strongly Oppose the Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  P  Elayne Poston  3879 Lost Shadows Cv  Memphis, TN 38128‐2416 pelaynep@gmail.com  92 Jonathan Reeve From: Sent: To: Subject: tyquruss mendes Wednesday, October 16, 2019 5:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenncare block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   As I read the proposal about the block grant there is no way to get the help need for the disabled, elderly or low income  people. There are many people on Medicare and Medicaid with very serious illness that need and take more than one  mediation, that would be limited by this proposal. There is no clear understanding of how it will work. All I can do is  think about the people who live in the rural area where hospital are closing and how they will have to travel for the help  they need. What's wrong with Medicare and Medicaid the way it is now ? I am one of disabled. Thank you very much for  time reading this.           93 Jonathan Reeve From: Sent: To: Valerie Newsom Wednesday, October 16, 2019 4:45 AM PUBLICE NOTICE TENNCARE AGAINST     Mrs.Andre’  94 Jonathan Reeve From: Sent: To: Subject: mguilbeau@building-ideas.net Tuesday, October 15, 2019 11:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Amendment 42     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Hello,    I strongly oppose this amendment.  Healthcare resources allocation should be based on an objective standard of care.   Capping the distributions of payments opens the door to the politicization of healthcare for the most vulnerable of  Tennessee’s people.  It also creates a whole new layer of beaurocracy, which I find an entirely ironic waste of precious  resources.      Better to tighten up the standards for what counts for medical care, and to look for better ways to control costs.    Sincerely,    Marcelle Guilbeau   Nashville, TN    Sent from my iPhone  95 Jonathan Reeve From: Sent: To: Subject: Ondrejcak Denise Tuesday, October 15, 2019 10:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] public comment     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Cancer outlooks for Americans are improving‐‐‐except in Tennessee. There is access to treatment for opiod addiction in  states that expand Medicaid‐‐‐not in Tennessee. The Volunteer State had an increase in uninsured in 2018‐‐the third  largest in the country. Tennessee leads the nation in rural hospital closings.   How would that affect medical spending in Tennessee‐‐with a national rate increasing faster than inflation? Yet the  legislature wishes to experiment with a block grant to manage medical costs. What about REAL care and concern for the  well being‐‐both health and financial‐‐of those least served‐‐not by the self‐serving block grant system proposed. Expand  TennCare. Denise Ondrejcak Franklin, TN.    96 Jonathan Reeve From: Sent: To: Subject: eav8@everyactioncustom.com on behalf of Emily Vergho Tuesday, October 15, 2019 8:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, including my son.  I am 70 and my 31 year old son lives with me.  He has autism,  extremely limited speech and other issues.  He cannot work or live independently.  Until I retired, he received services  which allowed me to work full time and insure him through my work health insurance.  He now relies on Medicare and  TennCare, in addition to other services.  I am extremely concerned for his future.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, behavioural therapy, speech therapy, hospice, and transplant coverage without normal federal oversight – and  arbitrarily limit who gets them. The proposal could also cut back on core health care services like hospital care, without  federal approval or public notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  Any cost savings from cutting services, curtailing eligibility, or reducing payments to providers will negatively impact  vulnerable Tennesseans like my son.  These cost savings would be diverted to the Tennessee budget rather than to  TennCare.  Money would be taken from the most vulnerable and given to the state legislature to spend as it wanted.   We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Emily Vergho  3216 Longacre Cv  Memphis, TN 38134‐3134 eav8@bellsouth.net  97 Jonathan Reeve From: Sent: To: Subject: Pamela Clayton Tuesday, October 15, 2019 7:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Against healthcare block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐    Against the healthcare block grant!!!!!          Thank you,  Pamela Clayton  98 Jonathan Reeve From: Sent: To: Subject: LSA Alexander Tuesday, October 15, 2019 7:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Save tenncare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am a social, please save tenncare..I will be watching...  99 Jonathan Reeve From: Sent: To: Subject: sareed307@everyactioncustom.com on behalf of Ash Reed Tuesday, October 15, 2019 6:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ash Reed  4352 Cambridge Dr  Antioch, TN 37013‐1131 sareed307@yahoo.com  100 Jonathan Reeve From: Sent: To: Subject: Michelle Gross Tuesday, October 15, 2019 6:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Re Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Knoxville Pyblic Comments  October 2, 2019    My name is Michelle Gross, I live in Upper East Tennessee with my two daughters. Asher is my younger daughter here with me and owns the title of “complex cutie.” She is a chronically ill child with complex medical needs and disabilities. I am here today as an advocate for all children with complex medical health care needs and disabilities, We oppose the impacts this amendment could have on the health care, benefits and services available to her and all children like her. Asher currently is covered by my commercial employer-sponsored insurance, as well as TennCare.  This proposal scares me and families like mine.Tennessee is asking to be exempt from future federal Medicaid mandates with minimal oversight and accountability to the federal government. Asher has a rare chromosomal translocation that places her in a category of unknown and complex. As she grows up , I have been told she may exhibit more traits of her individual chromosomal differences and therefore require additional services, new services, or breakthrough interventions. Without clear requirements and accountability to meet federal mandates, Tennessee has the authority to deny her services and supports necessary to her health and quality of life.  Another concern with this amendment is the adoption of a commercial-style closed prescription drug formulary which will greatly limit specialty medications that Asher and children like her require to survive and thrive. In just the last two months her respiratory health has required three hospitalizations and medications that insurance does not cover. Asher’s symptoms run parallel to another debilitating lung disease; however, her insurance denied the formulary intended for inhalation and approved the more cost-effective IM/IV formula. She inhaled this medication for 28 days, twice a day and though it treated her symptoms and the benefits outweighed the risks, the side effects she experienced were a severely sore throat, inability to maintain oral feeds, and failure to manage secretions. There are instances in which approving one drug in a therapeutic class, does not fit all patients equally. This proposal does not specify an appeals process for recipients with a medical need for a specialty drug that is excluded, which means my child may not be able to access the medication that she needs to help her breathe   This amendment permits Tennessee to cut or limit optional benefits that are vital to Asher’s ability to acquire life skills and thrive. Asher has poor fine and gross motor skills and requires weekly physical therapy and occupational therapy. She is dependent on a surgically placed feeding tube for primary nutrition and must have feeding and speech therapy every week. Asher has a history of respiratory failure and contracted RSV in Dec 2017, which resulted in a 40-day ICU stay including 6 days of advanced life support. With this amendment many mandatory benefits could experience limitations such as the former policy of covering only 14 days per year of in-patient hospital care. Asher has already been hospitalized four times this year far well exceeding that 14 day limit. Without necessary hospitalizations, she will die.   The limitations created by this amendment do not speak to supporting her health or health care. Amendment 42 requests the authority to limit the “amount, duration, and scope” of core benefits. This amendment does 101 very little to support Medicaid’s central goal of providing health coverage “for persons of all ages whose income and resources are insufficient to pay for health care”. I implore you to reconsider the life and death impacts this legislation will have for the chronically ill, rare disease, and disabled residents of our state.      102 Jonathan Reeve From: Sent: To: Subject: Nancy McFadden Tuesday, October 15, 2019 5:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I DISAPPROVE OF THE BLOCK GRANT RROPOSAL   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I believe the Block Grant, if approved, would hurt thousands of people. Due to our current funding, we have closed 12 hospitals in TN in rural areas. I do not see how spending less money will fix that. In addition, there are hundreds of thousands of people who have no health insurance. The block grant does not claim to help them. I live in Nashville about a mile from VUMC and close to other hospitals. I have good health coverage. But I do not care just for my family. In the Bible it says, "do unto others as you would have them do unto you." Governor Lee had a day of prayer. I don't disagree with that. However, I would like Governor Lee to pray to be more compassionate with those who need help. If he understood that, he would be a better governor. We need to see the "better angels" in Lee's cabinet so that health care will be available to all at a price they can afford. Nancy G. McFadden nmcfadden9@gmail.com 103 Jonathan Reeve From: Sent: To: Subject: Edward Simpson Tuesday, October 15, 2019 5:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Waiver Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Roberts,   I am submitting the following comments in response to the public notice inviting public comments on proposed Waiver  Amendment 42. I am a medical student at the University of Tennessee Health Science Center in Memphis and am very  concerned about the effects this would have on the patients I see in the clinic every day.   I am unequivocally opposed to this proposal that would radically change Tennessee’s Medicaid partnership with the  federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.  In addition, this proposal leaves many unanswered questions. For example, according to Governor Lee, the goal of this  proposal is to generate $2 billion in savings. If, as the proposal says, the state already “operates one of the most cost‐ effective Medicaid programs in the nation”, where exactly will these “savings” come from?  The people who are most in need of this program are those who will be most be affected, and these are people I see,  talk to, and do my best to help every day. If this were to take affect, not only will it be detrimental to these patients but  also it will even further limit my ability to serve these patients. This waiver is fundamentally flawed and cannot be fixed.  It goes against the goals and purpose of the Medicaid program. I respectfully urge you not to go forward with this  harmful proposal.  Sincerely,  Edward Simpson  104 Jonathan Reeve From: Sent: To: Subject: justingagethompson1@everyactioncustom.com on behalf of Justin Thompson Tuesday, October 15, 2019 5:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block the Block Grant!     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Please block the Block Grant Proposal.     I have a mental health disorder, as do my friends and neighbors, and many of us cannot work or access things that we  need. We rely on our Medicaid coverage to keep our illnesses under control, not only to pay for the appointments but  also for medication and rides to our appointments. We almost always need a cocktail of multiple medications that work  together to treat our symptoms, some of which don't work for us and we have to try more expensive options.    The Block Grant Proposal would put nearly 1.6 million people at risk of losing their healthcare, including access to  necessary and effective medications.  The federal regulations protecting our ability to access services ensures that we  have enough mental and physical health professionals to have services that would be accessible to all disabled people,  and allows us to choose our providers based on our specific needs.    The Block Grant will make our healthcare more expensive, excluding high cost drugs from coverage, such as Abilify,  which I need to get by, and without insurance it would cost over $1000. It would be impossible for me to get this  necessary medication on my own. It would also limit the already limited amount of prescriptions that are covered, which  will be life‐threatening for people with multiple conditions that heavily rely on their medications, like I do. In addition to  Abilify, I also take Depakote, Lithium, Norvasc, Atavan, Lamictal, and Cogen to treat my multiple physical and mental  health conditions.    I have Bipolar 1 Disorder as well as Manic‐Depression, Anxiety, and IBS. People who do not have access to proper  treatment for these mental disorders can become suicidal or even homicidal, putting themselves and others in danger.  Without the mental health medication that we need, more people who are already suffering will become dangers to  society, and we do not have the resources to handle that kind of mental health crisis.    The state already limits who can get Medicaid and this grant would remove the federal protections that ensure we can  get the best quality of care. People who would benefit from prevention, treatment, and recovery services will end up  draining even more resources by needing emergency treatment when their maintenance and prevention gets taken  away from them.     So please, for my health and safety as well as that of many, many other people in Tennessee, block the Block Grant  Proposal.    Sincerely,  Justin Thompson  3806 Mission View Ave Apt 104A Chattanooga, TN 37411‐5132 justingagethompson1@gmail.com  105 Jonathan Reeve From: Sent: To: Subject: Janet Hasson Tuesday, October 15, 2019 4:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, TennCare is important to our son who is bi-polar and has other mental health issues. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare has helped our son by paying for all of his medications and assisting with his bills for psychiatric counseling. We are concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” My husband and I are worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. In a time when mass shootings have become a national concern, it is imperative that good mental healthcare is provided for ALL of those who need it. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely, Janet S. Hasson James K. Hasson, Jr. 106 Jonathan Reeve From: Sent: To: Subject: dan.mceachern@everyactioncustom.com on behalf of Daniel McEachern Tuesday, October 15, 2019 3:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment OPPOSING Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Daniel McEachern  2953 Franklin Pike  Nashville, TN 37204‐3423 dan.mceachern@comcast.net  107 Jonathan Reeve From: Sent: To: Subject: bonnie chidester Tuesday, October 15, 2019 3:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose this. As a cost saving tactic it will not save money. It will destroy people’s ability to live. We have already  donated $7 Billion to other states by refusing to expand Medicaid.   I quote my sources here:   https://www.sycamoreinstitutetn.org/breaking‐down‐tenncares‐block‐grant‐proposal/  108 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of mjg795@gmail.com Tuesday, October 15, 2019 2:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries,  Tennessee's uninsured population, and the larger community of low‐incomeTennesseans as an employee in Nashville's  anti‐hunger sector.     As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐white populations, and others who experience discrimination in health care.     .    It has been widely proven that block granting federal programs designed to protect vulnerable populations is incredibly  detrimental to the well‐being of our communities. When TANF was converted from an entitlement program to a block  grant, research conducted from the Center for Budget and Policy Priorities has shown that money allocated for the  program was not put towards assisting low‐income families, but instead was diverted to fill budget holes. In addition,  the TANF allocation was not adjusted for inflation and thus has eroded poorly over time, losing one‐third of its value  since 1997. Overall, these two factors ‐‐ the funds' diminished value and broadened dispersal ‐‐ has left states with  fewer resources to serve vulnerable families. This has resulted in a large gap of needy families being left to provide for  themselves, despite having incomes that are well within the program's guidelines. The dramatic decrease of  participation in the program is reflective of this, going from 4 million in 1997 to 1.5 million in 2016, despite the number  of families in poverty remaining stagnant at nearly 6 million. Therefore block granting Medicaid directly goes against the  intended purpose of the program, and undermines the health of low‐income communities.    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Margaux Johnson‐Green  281 Cumberland Bend  Nashville, TN 37228‐1813  1 Jonathan Reeve From: Sent: To: Subject: Frank Bemis Tuesday, October 15, 2019 2:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grants--Healthcare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   We are opposed to block grants for healthcare. We believe Tennessee should do the medicaid expansion proposed by  former Governor Haslam. Six or seven partisan legislators refused to work with Haslam because they did not like  former  President Obama. This pettiness on their part is costing our state, as our tax dollars go to other states, and is also  denying healthcare to our needy and closing hospitals. Do the right thing and accept medicaid expansion  !                                               Frank and Kathie Bemis,  Knoxville  2 Jonathan Reeve From: Sent: To: Subject: Jennifer Coleman Tuesday, October 15, 2019 2:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts: Please accept my public comments for Amendment 42. As a mother of a young son with Down syndrome, I have a connection with disability issues and have a direct interest in legislation that affects citizens with developmental disabilities. I am concerned that by ending the current, open-ended federal match for Medicaid, Tennessee will experience reduced funding for all Medicaid services including the most crucial and life-sustaining for those with disabilities; long-term services and supports programs. Many of the services are specialized and not available outside of Medicaid. Essentially, without the open-ended federal match to fund long-term services and supports programs, we are concerned about the risk to Tennesseans with developmental disabilities in the future, even as the proposal includes an overall federal funding increase in the short-term. In addition I would recommend: -There be a plan for establishing checks and balances governing decisions about the program over time, which are currently provided by federal negotiations and oversight. For example: the appeals processes; changes to the amount, duration and scope of services; and regulations about provider network adequacy. - A plan for assuring transparency to the public, both inviting and considering public comment when changes are made to the program. This process is currently required by federal regulations. -Assurances that new limits to prescription drug coverage would be waived for people with rare conditions, behavioral health diagnoses, and disabilities. These populations often rely on specific choices among drugs within a classification and on “off label” drugs – both of which would be excluded from coverage under Amendment 42. Sincerely, Jennifer Coleman 3 Jonathan Reeve From: Sent: To: Subject: dondebsmith@everyactioncustom.com on behalf of don and deb smith Tuesday, October 15, 2019 1:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  don and deb smith  422 Dill Ln  Murfreesboro, TN 37130‐5807 dondebsmith@outlook.com  4 Jonathan Reeve From: Sent: To: Subject: ajonfrere@everyactioncustom.com on behalf of Jon Frere Tuesday, October 15, 2019 12:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Jon Frere  2109 32nd Ave S  Nashville, TN 37212‐4042 ajonfrere@gmail.com  5 Jonathan Reeve From: Sent: To: Subject: tracyt@everyactioncustom.com on behalf of Tracy Taylor Tuesday, October 15, 2019 7:01 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tracy Taylor  Chattanooga, TN 37409  tracyt@hamiltontn.gov  6 Jonathan Reeve From: Sent: To: Subject: hoakley017@everyactioncustom.com on behalf of Hannah Oakley Tuesday, October 15, 2019 7:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Hannah Oakley  1415 Roberts Ave  Nashville, TN 37206‐2524 hoakley017@gmail.com  7 Jonathan Reeve From: Sent: To: Subject: drsarawells@everyactioncustom.com on behalf of Sara Wells Tuesday, October 15, 2019 7:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.       As a urologist in rural TN, I routinely take care of medicare and medicaid patients, many of which have trouble getting  a ride to clinic, can’t drive themselves because of disability, many on supplemental oxygen and many on 15+  prescriptions ‐ none of which would be affordable without their insurance. These people need more help,  of the risk of  less. Despite frequent disability and lack of employment, even the sickest of these people still contribute to society and  are fiercely loved by family friends. They deserve our empathy and service.     sincerely,   Sara Wells,MD    Sincerely,  Dr. Sara Wells  Sewanee, TN 37375  drsarawells@gmail.com  8 Jonathan Reeve From: Sent: To: Subject: flemmingps@everyactioncustom.com on behalf of Patricia Flemming Tuesday, October 15, 2019 7:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr Patricia Flemming  Brentwood, TN 37027  flemmingps@comcast.net  9 Jonathan Reeve From: Sent: To: Subject: vburney@everyactioncustom.com on behalf of VICKI BURNEY Tuesday, October 15, 2019 7:38 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Without Tenncare coverage my aunt would not have been able to continue her much needed nursing home coverage.   The elderly low income people need this benefit.  They fall through the cracks with no one to speak up for them.    Sincerely,  VICKI BURNEY  PO Box 70426  Nashville, TN 37207‐0426  vburney@yahoo.com  10 Jonathan Reeve From: Sent: To: Subject: Megan Daniels Tuesday, October 15, 2019 8:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Megan Daniels   6345 Ridgewalk Lane  Knoxville, TN 37931   11 Jonathan Reeve From: Sent: To: Subject: Jacqueline Guerrero Tuesday, October 15, 2019 8:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and a mother of a child with cystic fibrosis (CF), I am writing to express my serious concerns  with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure without  federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled with  the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and reduced  benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Jacqueline Guerrero   107 Grapevine Rd  Hendersonville, TN 37075   12 Jonathan Reeve From: Sent: To: Subject: tphelps52@everyactioncustom.com on behalf of Marilyn Phelps Tuesday, October 15, 2019 8:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    It is all of our responsibility to care for those in need.  Providing good healthcare not only is the humane thing to do, it is  also a FISCALLY SMART THING TO DO.  Do what's right for those in need in our wonderful state, as well as doing what's  right for all of us.    Sincerely,  Marilyn Phelps  156 Morgans Steep Rd  Sewanee, TN 37375‐2031 tphelps52@gmail.com  13 Jonathan Reeve From: Sent: To: Subject: private4u2@everyactioncustom.com on behalf of Jennifer Clark Tuesday, October 15, 2019 8:32 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I wanted to express my concerns to you about the proposed Medicaid Block Grant.  I'm opposed to this proposal to  convert federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for many vulnerable Tennesseans who rely on this health insurance for their health and safety.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     I believe TennCare needs more accountability, not less. I work with TennCare daily in trying to get my client's basic  needs met and see the harm this proposal would bring. I'm already watching as a large amount of my child clients are  being denied coverage for which they are legally eligible.  To place another barrier in their care is quite concerning.     I believe the state should not be allowed to make changes to the Medicaid program without federal oversight or to  eliminate federal standards, which are in place for the protection of patients. Without such guardrails, the state could  return to the days when managed care contractors failed to provide care to patients and providers were left unpaid. This  proposal invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.      I have lived in Tennessee the majority of my life and have made healthcare my occupation for life.  I want to see  Tennessee create opportunities for its residents to obtain life‐saving health care services, not be blocked from them.     I respectfully urge you not to go forward with this harmful proposal.    Thank you so much for your concern for Tennessee's residents and for your consideration and wisdom concerning this  important issue.     Sincerely,    Jennifer Clark    Sincerely,  Jennifer Clark  Madison, TN 37115  private4u2@hushmail.com  14 Jonathan Reeve From: Sent: To: Subject: brianea1280@everyactioncustom.com on behalf of Brian Adkins Tuesday, October 15, 2019 9:06 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.  This includes our daughter Makayla.  She has many special needs.  Both her Mom  and I both work full time.  However, even with private insurance, the coverage often falls short.  She often has illnesses  that lands her at the doctors office, or sometimes hospitalized, medications, and ongoing equipment needs to improve  her quality of life.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Brian Adkins  388 Woodcrest Dr  Kingsport, TN 37663‐2328 brianea1280@gmail.com  15 Jonathan Reeve From: Sent: To: Subject: ash.riv96@everyactioncustom.com on behalf of Ashley Rivera Tuesday, October 15, 2019 8:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I personally work with populations who rely on Medicaid, and this would do great harm to them. As a nation, the health  of our people reflects the health of the nation.    Sincerely,  Ashley Rivera  Nashville, TN 37215  ash.riv96@gmail.com  16 Jonathan Reeve From: Sent: To: Subject: asri.mumpuni@everyactioncustom.com on behalf of Asri Mumpuni Tuesday, October 15, 2019 9:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I work for Vanderbilt University Medical Center and these opinions are my own.    I have worked for hospitals, including VA hospitals, in the past and feel very close to this issue. I have dedicated my life  to public health and protecting the health of those in my community. We all know and love someone who would be  affected negatively by this proposal. Please consider opposing it.    Thank you.    Sincerely,  Asri Mumpuni  Nashville, TN 37203  asri.mumpuni@vumc.org  17 Jonathan Reeve From: Sent: To: Subject: brady.watson22@everyactioncustom.com on behalf of Brady Watson Tuesday, October 15, 2019 9:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Brady Watson  Knoxville, TN 37920  brady.watson22@gmail.com  18 Jonathan Reeve From: Sent: To: Subject: dorothy.gager@everyactioncustom.com on behalf of Dorothy Gager Tuesday, October 15, 2019 9:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the current proposal for block grant for Tennessee's Medicaid program for a number of reasons.     Gov. Lee has just established a committee to advise him on ways to improve health care delivery in this state‐‐ after he  submitted the block grant proposal.  Shouldn't he gather information and recommendations first before presenting his  solution?     Gov. Lee has dismissed all opposition in public hearings because he thought the people in opposition simply did not  understand the complexity of his proposal. Those opponents were in large part professionals who have devoted their  careers to providing health care. Perhaps he should listen to them.     I have an adult son with multiple disabilities who has been a Tenncare recipient all of his life.  While it's not perfect, it  has provided him with surgery, various therapies, consistent medical care, and now housing under the ECF program.  These services have literally saved his life.  It terrifies me to think that he and thousands of other Tennesseans might be  covered by a plan that was designed to save money, not to provide high quality health care in the most efficient and  effective manner.      I am a retired Licensed Clinical Social Worker and have provided services to Tennessee Medicaid recipients for most of  my forty year career. I am haunted by memory of some individuals who lost their coverage in previous belt‐ tightening  plans.  Their lives matter!     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  Please do not  go forward with this harmful proposal.    Sincerely,  Dorothy Gager  920 Marengo Ln  Nashville, TN 37204‐3302 dorothy.gager@gmail.com  19 Jonathan Reeve From: Sent: To: Subject: erika.newberry@everyactioncustom.com on behalf of Erika Newberry Tuesday, October 15, 2019 9:28 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Erika Newberry  5210 Browder Hollow Rd  Lenoir City, TN 37771‐8120 erika.newberry@pcat.org  20 Jonathan Reeve From: Sent: To: Subject: mmc7951@everyactioncustom.com on behalf of Margaret Massey-Cox Tuesday, October 15, 2019 9:32 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Margaret Massey‐Cox  8036 Camberley Dr  Powell, TN 37849‐4217 mmc7951@aol.com  21 Jonathan Reeve From: Sent: To: Subject: BPAULSON@everyactioncustom.com on behalf of MERVIN PAULSON Tuesday, October 15, 2019 9:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. MERVIN PAULSON  365 Millwood Dr  Nashville, TN 37217‐1612 BPAULSON@AOL.COM  22 Jonathan Reeve From: Sent: To: Subject: francis.j.prael@everyactioncustom.com on behalf of Francis Prael Tuesday, October 15, 2019 9:49 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Francis Prael  2118 Acklen Ave  Nashville, TN 37212‐3531 francis.j.prael@vanderbilt.edu  23 Jonathan Reeve From: Sent: To: Subject: courtneydevore@everyactioncustom.com on behalf of Courtney DeVore Tuesday, October 15, 2019 9:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am writing to oppose the classification of TennCare as a block grant. Lower income families and people with disabilities  depend on the health coverage that TennCare offers. The block grant proposal goes against the objectives of Medicaid  because it gives Tennessee new authority to cut services for these vulnerable populations. Tennessee must care for  those that need aid by providing a system that has proper oversight so that incentives are properly aligned.    Thank you for reading this comment. I hope you will take this into consideration.     Best,    Sincerely,  Courtney DeVore  402 Theresa Ave Unit A Nashville, TN 37205‐2325 courtneydevore@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: kit.decker@everyactioncustom.com on behalf of Kathryn Decker Tuesday, October 15, 2019 10:04 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     Last year many TennCare recipients inadvertently lost their status under TennCare and although still meeting income  and medical requirements are needing to be added back onto the rolls, costing the state money it thought it had saved  with it's not well‐thought‐out disenrollment plan.   I truly believe that this proposal will also either cost Tennessee more  in state money as these persons are readded to the rolls and  to supplement for the loss of funds under the block grant  OR the state of Tennessee will abandon it's citizens in need. I believe in fiscal responsibility, but I also believe in meeting  the legitimate needs of children, families and individuals.  Also since Medicaid is the source of funding for many in  nursing homes, those costs will continue to rise both due to cost of living and increased number of elderly persons in  need.       This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Kathryn Decker  1291 Winter Springs Ln  Cordova, TN 38016‐8742 kit.decker@earthlink.net  25 Jonathan Reeve From: Sent: To: Subject: catdeppen@everyactioncustom.com on behalf of Cathy Deppen Tuesday, October 15, 2019 10:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I grew up in poverty in a small town in Tennessee, Cookeville. I had two uncles who were primary care physicians in  nearby Livingston and Carthage Tennessee. Thank god my family could rely on the generosity of my uncle's to provide  healthcare as my state has NEVER done an adequate job of providing even the most basic of care to those in need. In  1990 I entered medical school at The University of Tennessee College of Medicine in Memphis and saw first‐hand how  little change had occurred since my own childhood. As a medical student and as a practicing obstetrician/gynecologist in  Hermitage and Lebanon Tennessee, I witnessed the damage done to my patients by the ill‐conceived and horribly  mismanaged TennCare system. For twenty years my colleagues and I tried to fill in the gaps as best we could as the state  laid more and more of the burden of care at the feet of physicians, clinics, and hospitals. Near the beginning of my  career, TennCare insurance companies declared bankruptcy, and the state only reimbursed five cents on the dollar for  already greatly discounted care. Tennessee healthcare providers lost millions of dollars while those insurance companies  just walked away. Over the next several years the state continued to cut, limit, and deny care especially to pregnant  women, children, and the disabled...the exact population who need our care the most! Concurrently, our state  government allowed employers and insurers to opt out of providing women contraception and healthcare even when  pregnant. By the end of my career, I was writing off roughly fifty percent of charges to charity care as I could not in good  conscience add insult to injury. Now I am myself disabled and making my own personal decisions about what care I can  realistically afford to do without as more and more resources disappear daily. Therefore, I am vehemently opposed to  the proposal to radically change Tennessee’s Medicaid partnership with the federal government by converting federal  funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Clearly Tennessee's record of its ability to appropriately manage healthcare is abysmal. TennCare needs more  accountability, not less. The state should not be allowed to make changes to the Medicaid program without federal  oversight or eliminate federal standards, which are in place for the protection of patients. Without such guardrails, the  state could return to the days when managed care contractors failed to provide care to patients and providers were left  unpaid. This proposal invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Cathy Deppen  3510 Lealand Ln  Nashville, TN 37204‐3224 catdeppen@comcast.net  26 Jonathan Reeve From: Sent: To: Subject: p_weston@everyactioncustom.com on behalf of Pamela Weston Tuesday, October 15, 2019 10:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government with the  proposed TennCare “block grant.”     Medicaid was created to help give vulnerable Americans critical health care coverage.  This proposal is in opposition to  the goals established for Medicaid because it gives Tennessee the authority to cut services and opens the way for  eliminating services and restricting federal oversight.      Our medicaid program needs more accountability as it is.  Tennnessee should not be allowed to arbitrarily make changes  without federal oversight nor opting out of the federal standards that were established to protect people.  The block  grant proposal should be an absolute no!      I encourage you to not permit this 'block grant' proposal.  Just say 'No'!.    Sincerely,  Pamela Weston  PO Box 545  Sweetwater, TN 37874‐0545  p_weston@bellsouth.net  27 Jonathan Reeve From: Sent: To: Subject: dmonroe9356@everyactioncustom.com on behalf of Donna Monroe Tuesday, October 15, 2019 11:01 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Donna Monroe  Kingsport, TN 37660  dmonroe9356@charter.net  28 Jonathan Reeve From: Sent: To: Subject: Tammy sandidge Tuesday, October 15, 2019 11:05 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Tammy sandidge   245 Gatewood Rd  Surgoinsville, TN 37873   29 Jonathan Reeve From: Sent: To: Subject: judithgallagher53@everyactioncustom.com on behalf of Judy Gallagher Tuesday, October 15, 2019 11:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Judy Gallagher  730 Germantown Cir Apt 626 Chattanooga, TN 37412‐1857 judithgallagher53@gmail.com  30 Jonathan Reeve From: Sent: To: Subject: idaalward33366@everyactioncustom.com on behalf of Ida Rivera-Alward Tuesday, October 15, 2019 11:35 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Is in humane also to denie dental treatment for adults!!! .  Federal gov should do more for disavantish not everybody is  born with the same distany if that's was the case everyone would become president of the USA    This is a country takeing in thousand of people from all over the world most don't even belong here so the same way  this country offers help why not the poor Americans here!!   I'm speaking on behalf of the people and my daughter!!!!     Sincerely,  Ida Rivera‐Alward  123 N Bingham St Apt 13 Memphis, TN 38112‐3855 idaalward33366@gmail.com  31 Jonathan Reeve From: Sent: To: Subject: kaycemiller@everyactioncustom.com on behalf of Kayce Miller Tuesday, October 15, 2019 11:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans including myself.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kayce Miller  Mount Juliet, TN 37122  kaycemiller@gmail.com  32 Jonathan Reeve From: Sent: To: Subject: dusty.nave@everyactioncustom.com on behalf of Dusty Nave Tuesday, October 15, 2019 11:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dusty Nave  50 Daniel St  Savannah, TN 38372‐3539  dusty.nave@lifespanhealth.com  33 Jonathan Reeve From: Sent: To: Subject: schobaud@everyactioncustom.com on behalf of Danielle Schonbaum Tuesday, October 15, 2019 11:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Danielle Schonbaum  5576 Milford Rd  Memphis, TN 38120‐1809  schobaud@bellsouth.net  34 Jonathan Reeve From: Sent: To: Subject: jamiesloane@everyactioncustom.com on behalf of Jamie Johnson Tuesday, October 15, 2019 12:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I work at Memphis CHiLD, a medical‐legal partnership embedded at Memphis's nationally ranked pediatric hospital, Le  Bonheur.  Every week we talk with patients who already have significant challenges to receiving services to which they  are legally entitled under their TennCare health insurance.  More often than not, when we get involved, they receive  more services, and in turn, have better health outcomes.  While we are good at what we do, our success rate is too high  to be solely attributable to good advocacy; instead, the pattern is clear that the problem is systemic, and attributable to  problems with implementation, management, and oversight at TennCare.  These problems default to leaving our most  vulnerable children and their families without services they desperately need and to which they are untitled.  Those  children and families lucky enough to be patients at Le Bonheur or to otherwise have access to lawyers and advocates  are sometimes able to force TennCare to provide the services it is supposed to provide under the law ‐ but that is a  fraction of the population who is being harmed by TennCare's current approach.  The conversion of TennCare funding to  a block grant will exacerbate these problems because it will diminish oversight and accountability.        Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.        TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jamie Johnson  50 N Dunlap St  Memphis, TN 38103‐2800  35 jamiesloane@yahoo.com  36 Jonathan Reeve From: Sent: To: Subject: swalters@everyactioncustom.com on behalf of Scott Walters Tuesday, October 15, 2019 11:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rev. Scott Walters  Memphis, TN 38103  swalters@calvarymemphis.org  37 Jonathan Reeve From: Sent: To: Subject: schlacter9@everyactioncustom.com on behalf of Michael Schlacter Tuesday, October 15, 2019 11:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Additional information became available today, indicating 1 in 4 Tennessean’s have medical deb due to not having  insurance. The turn the decision over to the Legislative body of Tennessee and Governor would be irresponsible since  this situation is compounded by this Legislator body already closing hospitals and driving people off insurance care.  This  body needs all the money it can acquire to make affordable medical care available to all Tennesseans not just those in  major cities.  TennCare needs all the money it can get to relieve the indebtedness of the Poor and uninsured in  Tennessee.    Sincerely,  Mr. Michael Schlacter  6037 Brentwood Chase Dr  Brentwood, TN 37027‐4449 schlacter9@gmail.com  38 Jonathan Reeve From: Sent: To: Subject: juleweed@everyactioncustom.com on behalf of julie kornman Tuesday, October 15, 2019 11:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    STOP PUTTING PARTY OVER PEOPLE'S ACCESS TO HEALTH CARE!    Sincerely,  julie kornman  4500 Heath Rd  Nashville, TN 37221‐6603  juleweed@gmail.com  39 Jonathan Reeve From: Sent: To: Subject: pattyhartman1969@everyactioncustom.com on behalf of Patricia Hartman Tuesday, October 15, 2019 11:06 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patricia Hartman  Nashville, TN 37211  pattyhartman1969@gmail.com  40 Jonathan Reeve From: Sent: To: Subject: jeannefb@everyactioncustom.com on behalf of Jeanne Ballinger Tuesday, October 15, 2019 11:02 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments fron a 37-year general surgeon in Tennessee     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I have read the entire draft of TennCare11Demonstration Amendment42. I am a recently retired general surgeon in  practice in Tennessee for 37 years. I am well aware of the importance of having health insurance for the health and  financial stability of an individual. I am at a loss to explain why the Tn legislature and then governor turned down  expanding its Medicaid program that would have brought Federal money into the state and may have stopped the  closure of multiple rural hospitals that provide valuable care. I think it was a political decision. Therefore I do not feel the  state legislature and now governor are the ones to be making health care decisions about TennCare.    I have seen many patients who either died or had more serious health issues because they had no health insurance. One  example is a woman I took care of, who came to the emergency room with abdominal pain. She had no insurance. The  cause of her abdominal pain was metastatic breast cancer to the liver. She knew for at least a year that she had a lump  in her breast, but did not seek medical attention as she had no health insurance and thought it would be too expensive  to see a physician. She was not able to get TennCare until she had the diagnosis of breast cancer. In the long run it costs  more money to treat patients when illness is not caught early and in her case it cost her her life. I am strongly against  Amendment 42.     The state should expand Medicaid and with additional Federal dollars improve the health of Tennesseans.     Sincerely,  Dr. Jeanne Ballinger  3916 Kimpalong Dr  Nashville, TN 37205‐1950 jeannefb@aol.com  41 Jonathan Reeve From: Sent: To: Subject: Donna DeStefano Tuesday, October 15, 2019 10:01 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment RE: Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts, I am submitting the following comments regarding the proposed Amendment 42 to convert federal funding for TennCare into a block grant. As a Tennessee resident, I am gravely concerned about the proposed amendment and the harm that it will do to vulnerable people. The Medicaid Program was created to assist children, people with disabilities, pregnant women, and other vulnerable Americans get vital health coverage they need. This program has been a lifesaver for so many people that I have know both personally and professionally. It truly is a failsafe Program. Without it, they will suffer severe and irreparable harm to their health. I do not think that this what policymakers intend, but it is the reality of what will happen if this proposal goes into effect. This proposal would ultimately allow Tennessee new authority to cut services for these vulnerable populations. The state could eliminate or restrict services like hospice and transplant coverage -- and without the current federal oversight. Federal oversight has been and continues to be necessary to ensure that the Program operates for the benefit of those it serves and in keeping vulnerable populations as healthy as possible. I respectfully urge you not to go forward with this harmful proposal. Thank you for your time and consideration of these important comments. Sincerely, Donna DeStefano Nashville, TN 42 Jonathan Reeve From: Sent: To: Subject: honeycove@aol.com Tuesday, October 15, 2019 9:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenn Care Block Grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Governor Lee, Tennessee Legislators and other state officials, I am very much against the block grant proposal. As a person with mental illness in my family it would do financial harm to my family and limit the medical and mental health assistance to my family. This help is necessary for them to live a reasonably normal life. Persons with mental health issues are some of our state's most vulnerable and least able to defend themselves. Governor Lee, you state that you are a committed Christian. If you get this proposal passed you are going against the teachings of Christ. He Challenges us Christians to "take care of the least of these" . Mentally ill folks are certainly some of the"Least of these" . You need to think long and hard before you go against the teachings of Christ. If you want to improve the health of the poor and mentally ill in our state, you will expand our Tenncare system and accept federal money as most other states have done. Shame on you who do not have to worry about health care like most folks in Tennessee do. Think about what harm you are doing. Sincerely, William E. Honeycutt Hamilton County Citizen and registered voter. 532 Randall St Hixson, TN 37343 Proud Veteran of the US Navy Member of NAMI (National Alliance on Mental Illness) 43 Jonathan Reeve From: Sent: To: Subject: kmeier590@everyactioncustom.com on behalf of Kathleen Meier Tuesday, October 15, 2019 9:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Kathleen Meier  758 N Mclean Blvd  Memphis, TN 38107‐5114 kmeier590@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: craig.b@everyactioncustom.com on behalf of Bonnie Craig Tuesday, October 15, 2019 9:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    TennCare is the last state agency that should be given a blank check. Rather than ensuring all vulnerable Tennesseans  who are eligible for TennCare are getting the vital medical services they need, TennCare has systematically kicked  children and people with disabilities off their health coverage.    The block grant does nothing to address the real health concerns of Tennesseans. TN has some of the most daunting  challenges facing any state, including being among the worst in declining insurance coverage of children and rising rate  of rural hospital closures. Rather than adequately address Tennesseans’ real concerns, politicians have instead seized on  the block grant as a distraction from their failure to come up with real answers to our real and urgent problems.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.      Enabling the state to divert funds from the health care system and spend the money however it chooses is NOT  ACCEPTABLE.    Sincerely,  Mrs. Bonnie Craig  225 Bent Creek Trce  Nolensville, TN 37135‐2935 craig.b@att.net  45 Jonathan Reeve From: Sent: To: Subject: Lfnxphile87@everyactioncustom.com on behalf of Crystal White Tuesday, October 15, 2019 12:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Sir,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” I believe this proposal could cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee  personnel who are not necessarily in the medical profession new authority to cut services for these vulnerable  populations. The state could eliminate or restrict services like physical therapy, hospice, and transplant coverage  without normal federal oversight – and arbitrarily limit who gets them. The proposal could also cut back on core health  care services like hospital care, without federal approval or public notice, and exclude coverage of the most effective  prescription drugs.     I believe TennCare needs more accountability, not less. The state should not be allowed to make changes to the  Medicaid program without federal oversight or eliminate federal standards, which are in place for the protection of  patients. Without such guardrails, the state could return to the days when managed care contractors failed to provide  care to patients and providers were left unpaid. We all want healthcare that costs less, but healthcare from the lowest  bidder isn't always the best either.    This waiver is fundamentally flawed. It goes against the goals and purpose of the Medicaid program. I respectfully urge  you not to go forward with this harmful proposal.    Sincerely,  Crystal White  873 Hickory Oaks Cir  Collierville, TN 38017‐3205 Lfnxphile87@gmail.com  46 Jonathan Reeve From: Sent: To: Subject: Alice Hudson Tuesday, October 15, 2019 2:36 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Alice Hudson   3816 Piper Bay Cove  Lakeland, TN 38002   47 Jonathan Reeve From: Sent: To: Subject: Kimberly Hewell Tuesday, October 15, 2019 5:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Kimberly Hewell   616 Hillwood Blvd  Nashville, TN 37205   48 Jonathan Reeve From: Sent: To: Subject: dzmom46@everyactioncustom.com on behalf of Denise Smith Tuesday, October 15, 2019 6:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Somehow when a 2‐bed facility, which is nothing more than a pitstop for the rescue squad, can be called "Johnson  County Hospital" ‐ and this is after the Ballad Health takeover which isn't working too well for the people ‐ the idea that  administration of a block grant to the State is ludicrous.  PLEASE DON'T DO IT!    Sincerely,  Mrs. Denise Smith  167 Circle View Dr  Mountain City, TN 37683‐1557 dzmom46@charter.net  49 Jonathan Reeve From: Sent: To: Subject: sew.griswold@everyactioncustom.com on behalf of Sarah Griswold Tuesday, October 15, 2019 8:32 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment: Opposition to the Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     As a dietitian and nutrition director in the Supplemental Nutrition Program for Women, Infants, and Children, I work  with many families who rely on TennCare for health care services. Access to health care is vitally important in the  earliest stages of life and continues to be necessary throughout the lifespan. Healthy citizens are more able to learn,  produce, and participate in a thriving society. Illness and disease are costly, so investment in prevention and wellness  through regular health care can mitigate some of that cost.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sarah Griswold  5020 Jacksboro Pike  Knoxville, TN 37918‐1844 sew.griswold@gmail.com  50 Jonathan Reeve From: Sent: To: Subject: Patricia Nance Monday, October 14, 2019 8:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Patricia Nance   1062 Yuma Rd  Wildersville, TN 38388   51 Jonathan Reeve From: Sent: To: Subject: bigcatman@everyactioncustom.com on behalf of C.B.Horton Jr. Monday, October 14, 2019 8:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. C.B. Horton Jr.  930 Industrial Dr Apt 416 Old Hickory, TN 37138‐3658 bigcatman@bellsouth.net  52 Jonathan Reeve From: Sent: To: Subject: bigcatman@everyactioncustom.com on behalf of C.B.Horton Jr. Monday, October 14, 2019 8:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. C.B. Horton Jr.  930 Industrial Dr Apt 416 Old Hickory, TN 37138‐3658 bigcatman@bellsouth.net  53 Jonathan Reeve From: Sent: To: Subject: John Tibbels Monday, October 14, 2019 8:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   John Tibbels   10077 Woodland Pine Cove East  Lakeland, TN 38002   54 Jonathan Reeve From: Sent: To: Subject: bonniekblack@everyactioncustom.com on behalf of Bonnie Black Monday, October 14, 2019 8:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Two organizations that I trust oppose the block grant, The League of Women Voters TN and the TN Justice Center.  They  have researched this concept thoroughly.The limited medication formulary may save money but mean that those  covered go without meds they really need.  Please reconsider that.       Federal government oversight is needed too of this program and my understanding the block grant would be free of that  oversight.     from Bonnie Black    Sincerely,  Bonnie Black  513 N Maney Ave  Murfreesboro, TN 37130‐2922 bonniekblack@gmail.com  55 Jonathan Reeve From: Sent: To: Subject: leahs579@everyactioncustom.com on behalf of Leah Smith Monday, October 14, 2019 8:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. My son is on Social security a disability and has a  traumatic  brain injury we cannot afford for ANY of his coverage being eliminated. I am also a nurse practitioner and my  patients can not afford to lose their coverage either. Please vote no.      Sincerely,  Ms Leah Smith  176 Higgins Rd  Brighton, TN 38011‐3602  leahs579@gmail.com  56 Jonathan Reeve From: Sent: To: Subject: munronb@everyactioncustom.com on behalf of Nancy Munro Monday, October 14, 2019 8:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    My husband and I are strongly opposed to the proposal to radically change Tennessee’s Medicaid partnership  with the  federal government by converting federal funding for TennCare into a “block grant.” This proposal would jeopardize  coverage for vulnerable Tennesseans and thus potentially greatly harm many people.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.    My mother was served by the Choices program under TennCare first as a participant in an adult day program when she  first came to live with us (Choices was brand new and went by another name then).  She also had 12 hours a week of  home help from a CNA who assisted her with bath and other personal care plus a bit of light housework; the object was  to give her help so she could live at home and avoid nursing home care.  She had many medical issues and was in and  out of the hospital with increasing frequency but Choices made it possible for her to return home each time.  It also  enable me to continue working 12 hours a week and care for her in the intervening hours/days.  Much later my mother  was approved for long term care at a nursing home under the Choices program but only needed that care for 2 1/2  months before she passed away after being with us at home for the previous 2 1/2+ years.  Thus Choices was a highly  cost effective program for her.      Prior to that, my mother‐in‐law was served by TennCare (Medicaid) for about 8 years as a resident of a local nursing  home when her Alzheimer's disease became advanced enough that her husband couldn't give her adequate care at  home (he had health issues himself).  Choices was not available at that time to provide any in‐home care.      The standards at that time were minimally adequate and the funding not adequate for that nursing home (considered  the best in Oak Ridge) or any other to provide high quality care.  Any deterioration of funding and standards would be a  huge disservice to Tennesseans needing long‐term nursing home care.  With the epidemics of Alzheimer's disease,  diabetes, obesity, stroke and other cardiovascular diseases now ramping up, the need for nursing home care will  accelerate for the foreseeable future and TennCare will be essential to fund the care for many Tennesseans of minimal  or modest means.  Having a block grant that caps the Medicaid funding would thus be a disaster for Tennesseans.    TennCare needs more accountability, not less. The state should NOT be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully but very strongly urge you not to go forward with this harmful proposal.    57 Sincerely,  Nancy Munro  1351 Tuskegee Dr  Oak Ridge, TN 37830‐5918 munronb@comcast.net  58 Jonathan Reeve From: Sent: To: Subject: karenkay885@everyactioncustom.com on behalf of Karen Reynolds Monday, October 14, 2019 8:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Karen Reynolds  700 W Creek Dr  Clarksville, TN 37040‐6018 karenkay885@yahoo.com  59 Jonathan Reeve From: Sent: To: Subject: Christina Mila Monday, October 14, 2019 9:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and both a parent and sibling of individuals affected by cystic fibrosis (CF), I am writing to  express my serious concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s  benefits structure without federal oversight, implement a closed formulary, and waive additional federal Medicaid  requirements – coupled with the proposed block grant financing structure – could lead to limited eligibility, decreased  access to care, and reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Christina Mila   1709 Haleys Hope Court  Nashville, TN 37209   60 Jonathan Reeve From: Sent: To: Subject: jnb45@everyactioncustom.com on behalf of Jerrie Barnett-Whitlow Monday, October 14, 2019 9:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. I am aware of this personally because I had a 44‐year‐old son with multiple challenges  who was on TennCare for more than half his life. He died in September 2018: his health was fragile and he was on  multiple medications; he required many hospital stays. His father and I both worked, and we still would have been  bankrupt without TennCare. And I know many families in similar or worse situations: I taught at TENNESSEE SCHOOL  FOR THE BLIND for 17 years, and the great majority of our families were/still are dependent on TennCare. This proposal  goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these vulnerable  populations. The state could eliminate or restrict services like physical therapy, hospice, and transplant coverage  without normal federal oversight – and arbitrarily limit who gets them. The proposal could also cut back on core health  care services like hospital care, without federal approval or public notice, and exclude coverage of the most effective  prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Jerrie Barnett‐Whitlow  5109 W Concord Rd  Brentwood, TN 37027‐6531 jnb45@yahoo.com  61 Jonathan Reeve From: Sent: To: Subject: hugginsd92@everyactioncustom.com on behalf of Donna Huggins Monday, October 14, 2019 9:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Donna Huggins  1126 Rebecca Dr  Burns, TN 37029‐6035  hugginsd92@yahoo.com  62 Jonathan Reeve From: Sent: To: Subject: daviscrew03@everyactioncustom.com on behalf of Amy DavisIsbill Monday, October 14, 2019 9:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I can not believe you would do this you suppose to be looking out for TN citizens!!!! Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amy DavisIsbill  2146 Mentor Rd  Louisville, TN 37777‐4003 daviscrew03@yahoo.com  63 Jonathan Reeve From: Sent: To: Subject: LEBittrich@everyactioncustom.com on behalf of Louis Bittrich Monday, October 14, 2019 9:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] It ;used to be possible to be proud of TN's TennCare. Please bring us back to those days of justice and compassion.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr Louis Bittrich  1927 Memorial Blvd # A255 Murfreesboro, TN 37129‐1545 LEBittrich@gmail.com  64 Jonathan Reeve From: Sent: To: Subject: r.paul.ledbetter@everyactioncustom.com on behalf of Robert Ledbetter Monday, October 14, 2019 9:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a medical student in North Carolina with who pays particular attention to policies regarding health care access and  how introducing barriers to access will disincentivize preventative care and lead people to have catastrophic disease  states that are both ruinous to the lives of the people who experience them, but detrimental to the society that  collectively affords these increased costs. Nothing happens in a vacuum and we can very easily see the ramifications of  this proposal.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Robert Ledbetter  2728 Pulaski Hwy  Columbia, TN 38401‐5716 r.paul.ledbetter@gmail.com  65 Jonathan Reeve From: Sent: To: Subject: sabinnne@everyactioncustom.com on behalf of Rachael OQuinn Monday, October 14, 2019 9:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rachael OQuinn  1204 Hampton Road Dr  La Vergne, TN 37086‐2698 sabinnne@gmail.com  66 Jonathan Reeve From: Sent: To: Subject: Calea Davis Monday, October 14, 2019 10:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF)‐my husband battles this terrible  disease, I am writing to express my serious concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request  to change TennCare’s benefits structure without federal oversight, implement a closed formulary, and waive additional  federal Medicaid requirements – coupled with the proposed block grant financing structure – could lead to limited  eligibility, decreased access to care, and reduced benefits for people with CF who rely on TennCare. I urge you to  reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Calea Davis   4805 MILNER DR  Nashville, TN 37211   67 Jonathan Reeve From: Sent: To: Subject: msjok@everyactioncustom.com on behalf of Willette Johnson Monday, October 14, 2019 10:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] OPPOSING MEDICAID BLOCK GRANT PROGRAM   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Willette Johnson  4545 Dorff Dr  Memphis, TN 38116‐7103  msjok@bellsouth.net  68 Jonathan Reeve From: Sent: To: Subject: Stephanie Chandler Monday, October 14, 2019 10:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Stephanie Chandler   1419 Meridian St  Nashville, TN 37207   69 Jonathan Reeve From: Sent: To: Subject: Lbutler@everyactioncustom.com on behalf of Lorrie Butler Monday, October 14, 2019 10:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I oppose turning Medicaid coverage over to an experiment that will harm Tennesseans.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lorrie Butler  8255 State Route 200  Henderson, TN 38340‐7258 Lbutler@tnea.org  70 Jonathan Reeve From: Sent: To: Subject: penderam@everyactioncustom.com on behalf of Anne-Marie Pender Monday, October 14, 2019 10:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I am opposing the Medicare Block Grant.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Anne‐Marie Pender  61 Gipson Ln  Decherd, TN 37324‐4057  penderam@yahoo.com  71 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of dbakernurse@msn.com Tuesday, October 15, 2019 8:19 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Diana Baker  5179 Normandy Lane  Memphis, TN 38117‐2850   72 Jonathan Reeve From: Sent: To: Subject: Angela Orio Tuesday, October 15, 2019 8:06 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, TennCare is important to Me. It provides comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare has helped my friend by providing treatment to manage their Bipolar 1, without this program my friend would be unstable and unable to manage their daily activities. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely, Angela Orio   73 Jonathan Reeve From: Sent: To: Subject: johnselser@everyactioncustom.com on behalf of John Selser Monday, October 14, 2019 4:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     THE BLOCK GRANT PROPOSAL DOES NOTHING TO ADDRESS THE REAL HEALTH CONCERNS OF THE PEOPLE OF  TENNESSEE.  I truly believe it is a scam to cut back on providing health care to Tennesseans.  I wish people would be  upfront with their motives.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. John Selser  311 Nave St  Clinton, TN 37716‐3817  johnselser@att.net  74 Jonathan Reeve From: Sent: To: Subject: ics23@everyactioncustom.com on behalf of Ida Sharfner Monday, October 14, 2019 4:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ida Sharfner  Lebanon, TN 37087  ics23@bellsouth.net  75 Jonathan Reeve From: Sent: To: Subject: reddick@everyactioncustom.com on behalf of Allen Reddick Monday, October 14, 2019 4:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I am agains the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to this proposal. I live in the chronically poor county of Franklin, with a lot of people needing health care  and with insufficient funds and professionals to care for them. With this grant proposal, there will be even less oversight  for the programs and facilities these people need. Many, if not most, members of the communities of Sewanee,  Monteagle, Tracy City, Altamont, and Cowan are against this proposal. Please do more to help us, not less! Thanks to a  fair Medicaid, we have a chance to treat this population. Please do not tamper with it! We‐‐they‐‐need more  transparency and accountability, not less! I do not trust the State government to dispense care in a fair and equitable  way. I do, however, trust the traditional Medicare system.    Sincerely,    Prof. Allen Reddick    Sincerely,  Dr. Allen Reddick  104 Morgans Steep Rd  Sewanee, TN 37375‐2031 reddick@es.uzh.ch  76 Jonathan Reeve From: Sent: To: Subject: Gwynn Crider Monday, October 14, 2019 4:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Gwynn Crider   452 Hickory Nut Trl  Humboldt, TN 38343   77 Jonathan Reeve From: Sent: To: Subject: tharonkirk@everyactioncustom.com on behalf of Tharon Kirk Monday, October 14, 2019 4:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs. As a former Family nurse practitioner, I believe we need  to make health care more of a priority. We do not need to be cutting services!    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tharon Kirk  951 Morning Rd  Antioch, TN 37013‐4694  tharonkirk@gmail.com  78 Jonathan Reeve From: Sent: To: Subject: Daughertya77@everyactioncustom.com on behalf of Andrea Daugherty Monday, October 14, 2019 4:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Andrea Daugherty  7804 Stanley Rd  Powell, TN 37849‐4153  Daughertya77@yahoo.com  79 Jonathan Reeve From: Sent: To: Subject: mowers1974@everyactioncustom.com on behalf of DIANE MOWERS Monday, October 14, 2019 4:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  DIANE MOWERS  1140 Swann Ridge Rd  Hilham, TN 38568‐6052 mowers1974@gmail.com  80 Jonathan Reeve From: Sent: To: Subject: firegrunt@everyactioncustom.com on behalf of John Andes Monday, October 14, 2019 4:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am strongly opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes directly against those objectives of Medicaid because it gives  Tennessee new authority to cut services for these vulnerable populations. The state could eliminate or restrict services  like physical therapy, hospice, and transplant coverage without normal federal oversight and, worse,  arbitrarily limit  who gets them. The proposal could also cut back on core health care services like hospital care, without federal approval  or public notice, and exclude coverage of the most effective prescription drugs. This is NOT an acceptable approach to  health care in Tennessee.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.     Sincerely,  Mr. John Andes  300 Estate Dr  Mount Juliet, TN 37122‐2032 firegrunt@tds.net  81 Jonathan Reeve From: Sent: To: Subject: julrensta@everyactioncustom.com on behalf of Julyne Stanton Monday, October 14, 2019 4:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Julyne Stanton  2009 Layman Rd Apt 41 Athens, TN 37303‐4980 julrensta@gmail.com  82 Jonathan Reeve From: Sent: To: Subject: rabideauca@everyactioncustom.com on behalf of Carol Rabideau Monday, October 14, 2019 4:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Carol Rabideau  4010 Auburn Ln  Nashville, TN 37215‐1725 rabideauca@gmail.com  83 Jonathan Reeve From: Sent: To: Subject: kimmelbriggs@everyactioncustom.com on behalf of Carole Kimmel Monday, October 14, 2019 4:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Carole Kimmel  211 Union St  Nashville, TN 37201‐1500  kimmelbriggs@comcast.net  84 Jonathan Reeve From: Sent: To: Subject: dacabutler@everyactioncustom.com on behalf of David Butler Monday, October 14, 2019 4:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. David Butler  35 Asbury Ln  Hermitage, TN 37076‐2166  dacabutler@gmail.com  85 Jonathan Reeve From: Sent: To: Subject: Martha Smith Monday, October 14, 2019 4:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Martha Smith   949 Cairn Creek Dr  Memphis, TN 38018   86 Jonathan Reeve From: Sent: To: Subject: jw10ec@everyactioncustom.com on behalf of Joshua Williams Monday, October 14, 2019 4:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Insult to Injury:Medicaid Block Grant Proposal   Dear Gabe Roberts,    Failing to expand Medicaid has cost lives, rural hospitals, jobs, precious taxpayer funds  and public access to healthcare.  To add insult to injury you propose to accept block grants for Medicaid.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Joshua Williams  123 Forest Ct  Knoxville, TN 37919‐5078  jw10ec@aol.com  87 Jonathan Reeve From: Sent: To: Subject: dendee66@everyactioncustom.com on behalf of delaney lichtenwalter Monday, October 14, 2019 4:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.      PLEASE SCRAP THIS PROPOSAL IT WILL END UP MAKING TENNESEANS SICKER   THANKS    Sincerely,  mr delaney lichtenwalter  241 Sigman Hollow Rd  Bluff City, TN 37618‐4618 dendee66@att.net  88 Jonathan Reeve From: Sent: To: Subject: lindanelson1@everyactioncustom.com on behalf of Linda Nelson Monday, October 14, 2019 4:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Linda Nelson  578 Center Dr  Memphis, TN 38112‐1702  lindanelson1@mac.com  89 Jonathan Reeve From: Sent: To: Subject: jainerain@everyactioncustom.com on behalf of Jane Morris Monday, October 14, 2019 4:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.       I am writing on behalf of my ex‐husband, Gary, who had a brain seizure in November, 2014.  At this time it was  discovered that he also has lung cancer. He has received radiation treatment and the cancer is still there but not  spreading further at this time.   He does not use a computer and can barely manage a cell phone so I handle all of the  "online" communications for him.  Before we were divorced this happened.  We were divorced in 2017, but before that,  we were victims of the wildfires in Gatlinburg, TN and lost everything we had except our cat and the clothes on our  backs and the car we drove.   This block grant would be a major devastation for him and he would not be able to even  manuver communications via computer if anything were to happen to me.  It would totally render him unable to obtain  his medications and his Drs. visits for treatments, cat scans, tests etc.  He also was diagnosed with severe Rheumatoid  Arthritis.  Please, do not allow this Medicaid Block Grant to happen.  He doesn't have a whole lot of years left but this  would make what he does have left, unbearable without his RA meds.  It would be a death sentence to thousands of  hard‐working Tennesseans.  Jane Morris      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Jane Morris  PO Box 1493  Gatlinburg, TN 37738‐1493  jainerain@hotmail.com  90 Jonathan Reeve From: Sent: To: Subject: nimornam@everyactioncustom.com on behalf of Lara Firrone Monday, October 14, 2019 4:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I work in healthcare and we need more Medicaid, not less.  The ripple effects are closing the smaller hospitals and  driving the safety down in larger ones as we have to do more with less.  Physical therapy is a cost effective way to  maintain health and taking it away from the most vulnerable is ethically and morally wrong.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lara Firrone  3762 Allandale Rd  Memphis, TN 38111‐6504 nimornam@aol.com  91 Jonathan Reeve From: Sent: To: Subject: Laura Ketcham Monday, October 14, 2019 4:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Laura Ketcham   8431 Keystone Cir  Chattanooga, TN 37421   92 Jonathan Reeve From: Sent: To: Subject: janepsimmons@everyactioncustom.com on behalf of Emily Simmons Monday, October 14, 2019 4:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal - I have personal experience   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     I was a perinatal socialworker in the 1980's and early '90's.  I remember life under block grants.  It was not good either  for the patient seeking care, or the health care provider trying to stretch limited dollars.  The TennCare 3:1 match was a  godsend to all.  Please think before you mess with that!    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    (Emily) Jane P. Simmons, ACSW, LCSW (retired)    Sincerely,  Mrs. Emily Simmons  877 Clay Pl  Spring Hill, TN 37174‐3220  janepsimmons@comcast.net  93 Jonathan Reeve From: Sent: To: Subject: dlf.dolsom@everyactioncustom.com on behalf of David Folsom Monday, October 14, 2019 5:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    It's time to stop the neo‐Nazi GOP in Tennessee who line their own pockets with favors & exemptions only to have the  taxpayer foot the bill for THEIR exclusive medical insurance, all the while trying to hide it from the public!    Sincerely,  Mr. David Folsom  930 County Line Rd  Alexandria, TN 37012‐3584 dlf.dolsom@gmail.com  94 Jonathan Reeve From: Sent: To: Subject: Rheacerdave14@everyactioncustom.com on behalf of J.David Hester Monday, October 14, 2019 5:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. J. David Hester  134 Housley Cir  Dayton, TN 37321‐4307  Rheacerdave14@yahoo.com  95 Jonathan Reeve From: Sent: To: Subject: Bridget Bumpus-Morgan Monday, October 14, 2019 5:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     Four of my siblings were born with CF. They would not have made it to adulthood without the treatments, access to  breathing equipment, and the care they regularly needed and received. CF patients—or CF Warriors, as my family calls  them—didn’t choose to have this disease. But, they battle it every single day of their lives. The least we can do is provide  them with all the tools they need to have the best quality of life they can.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Bridget Bumpus‐Morgan   1717 Spencer Dr  Maryville, TN 37801   96 Jonathan Reeve From: Sent: To: Subject: autism-mom@everyactioncustom.com on behalf of Cynthia Brandon Monday, October 14, 2019 5:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.  My son has autism and could directly be affected among others that have  disabilities     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Cynthia Brandon  2561 Hale Ave  Memphis, TN 38112‐3329  autism‐mom@hotmail.com  97 Jonathan Reeve From: Sent: To: Subject: JSNOWROD16@everyactioncustom.com on behalf of Janice Rodriguez Monday, October 14, 2019 5:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Janice Rodriguez  1726 25th Ave N  Nashville, TN 37208‐1904 JSNOWROD16@GMAIL.COM  98 Jonathan Reeve From: Sent: To: Subject: Heather Goodman Monday, October 14, 2019 5:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Heather Goodman   4719 Lascassas Pike  Lascassas, TN 37085   99 Jonathan Reeve From: Sent: To: Subject: carole37122@everyactioncustom.com on behalf of Margaret Robertson Monday, October 14, 2019 5:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Margaret Robertson  113 Clark Dr # 37122 Mount Juliet, TN 37122‐4103 carole37122@yahoo.com  100 Jonathan Reeve From: Sent: To: Subject: micrayrus@everyactioncustom.com on behalf of Michael Russell Monday, October 14, 2019 5:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    We are opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal will almost certainly cause immense harm  and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposed change goes against the objectives of Medicaid because it gives  Tennessee new authority to cut services for these vulnerable populations. The state could eliminate or restrict services  like physical therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets  them. The proposal could also cut back on core health care services like hospital care, without federal approval or public  notice, and exclude coverage of the most effective prescription drugs.     TennCare needs rigorous accountability, not more lax oversight. The state should not be allowed to make changes to the  Medicaid program without federal oversight or to eliminate federal standards, which are in place for the protection of  patients. Without such guardrails, the state could return to the days when managed care contractors failed to provide  care to patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of  vital health coverage for Tennesseans. We are shocked the proposed changes are even being considered.    This waiver is fundamentally flawed. It goes against the goals and purpose of the Medicaid program. We respectfully  urge you not to go forward with this harmful proposal.    Sincerely,  Mr. and Mr Michael Russell  8180 Whites Creek Pike  Joelton, TN 37080‐8873 micrayrus@comcast.net  101 Jonathan Reeve From: Sent: To: Subject: ddnichol@everyactioncustom.com on behalf of Donald Nichols Monday, October 14, 2019 6:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a licensed Psychologist and the parent of a deaf son I am opposed to any legislation or decision that limits the  services to those in most need.       Please concern the welfare of the most vulnerable Tennessee citizens in the decisionmaking process.  Thanks,   Dr.  Donald D. Nichols, Pikeville    Sincerely,  Dr. Donald Nichols  1483 Hugh Allison Rd  Pikeville, TN 37367‐8006 ddnichol@gmail.com  102 Jonathan Reeve From: Sent: To: Subject: jpwilliehussey@everyactioncustom.com on behalf of Johnnie Hissey Monday, October 14, 2019 6:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I live in rural Tennessee where hospitals are closing. My husband died of a heart attack at home. It took medical help 45  minutes to get here. The hospital closing will add more to this time. THIS IS A MATTER OF LIFE OR DEATH.    My mentally challenged Sister lives with me. I am 67 years old living on retirement. Any cuts to her TennCare would be  devasating to our budget. PLEASE NO CUTS.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Sincerely    Johnnie Hussey    Sincerely,  Johnnie Hissey  400 Buck Fall Rd  Grand Junction, TN 38039‐3607 jpwilliehussey@bellsouth.net  1 Jonathan Reeve From: Sent: To: Subject: sylviawoodsknox@everyactioncustom.com on behalf of Sylvia Woods Monday, October 14, 2019 6:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     The state should not be allowed to make changes to the Medicaid program without federal oversight or eliminate  federal standards, which are in place for the protection of patients. Without such guardrails, the state could return to  the days when managed care contractors failed to provide care to patients and providers were left unpaid. This proposal  invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Tennessee government has not shown that they can manage healthcare for the benefit for people.  Just the idea of  trying to make a profit off of healthcare tells me they are not even trying to cover more of the needs of our citizens.   PLEASE DON'T APPROVE THIS TERRIBLE PLAN.    Sincerely,  Sylvia Woods  412 E Moody Ave  Knoxville, TN 37920‐4208 sylviawoodsknox@aol.com  2 Jonathan Reeve From: Sent: To: Subject: vickycgalloway@everyactioncustom.com on behalf of Vicky Galloway Monday, October 14, 2019 6:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    There is real danger this will be privatized and become a boondoggle for the citizens. Tennessee does not have a good  track record where money like this is involved.    TennCare already has problems that need to be addressed. Some of these are administrative. My daughter has two  boys. Last winter when they were taken for a routine checkup she discovered one had lost coverage. For several months  she sent in paperwork and jumped through hoops to get it straightened out. He got the coverage back. But the other  one lost his and she had to do it all over again. No one could explain why or what happened.    We do not need more administrative mess added to the current level. This will become a nightmare with little money  actually going to healthcare as most will be eaten up by administrative costs.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Vicky Galloway  1840 Bristol Hwy  Watauga, TN 37694‐3198 vickycgalloway@gmail.com  3 Jonathan Reeve From: Sent: To: Subject: samantha.swift@everyactioncustom.com on behalf of Samantha Swift Monday, October 14, 2019 6:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal of converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for thousands of vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs. This is unacceptable.    Every day I work with patients who benefit from TennCare, and the coverage it provides to them is indispensable.  Without it, their barriers to the care they need would increase drastically; many of them simply wouldn't be able to  afford even the most essential aspects of their care. For example, a diabetic patient who qualifies for TennCare would  not be able to afford the out‐of‐pocket prices of insulin.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful, reckless proposal.    Sincerely,  Samantha Swift  3349 Oak Trees Ct  Antioch, TN 37013‐1292 samantha.swift@ascension.org  4 Jonathan Reeve From: Sent: To: Subject: kponow@everyactioncustom.com on behalf of Karen Daniel Monday, October 14, 2019 6:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Karen Daniel  8207 Sawyer Brown Rd  Nashville, TN 37221‐2500 kponow@aol.com  5 Jonathan Reeve From: Sent: To: Subject: judyroitman@everyactioncustom.com on behalf of Judith Roitman Monday, October 14, 2019 6:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Jimmy Kimmel said “No parent should ever have to decide if they can afford to save their child’s life.” If the Tennessee  State legislature approves the proposal to switch TennCare to a block grant program, that impossible decision will be  their legacy.  Currently, over 690,000 children in Tennessee depend on TennCare for health insurance. For those who are healthy,  TennCare will cover the care they need to have a healthy start in life, from prenatal care to immunizations and well child  visits. Likewise, for those who are born with birth defects or who contract serious childhood illnesses, TennCare provides  insurance that they receive quality medical care.  If Tennessee switches TennCare to block grants, that guarantee is gone. TennCare will quit paying when the program  runs out of money. Imagine what that might mean to a child with Type 1 Diabetes who can no longer get insulin, or a  child battling leukemia who can no longer get hospital treatment. Picture what would happen if the program runs out of  money in November and a baby is born with a heart defect in December.  Block grants are not an easy fix to the problem of health care spending. They are an assault on the health of Tennessee’s  children. I urge the Tennessee legislature to reject making TennCare a block grant program. Don’t make Tennessee  parents have to decide if they can afford to save their child’s life.    TennCare needs more accountability, not less. I work as a health care social worker and I frequently see patients who  are thrown off the TennCare rolls with no notice and no reason. For example, 1 little boy was disenrolled while his older  siblings stayed on.  His parents tried for 6 moths to get him back on. The state should not be allowed to make changes to  the Medicaid program without federal oversight or eliminate federal standards, which are in place for the protection of  patients. Without such guardrails, the state could return to the days when managed care contractors failed to provide  care to patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of  vital health coverage for Tennesseans.         Sincerely,  Judith Roitman  103 Olney Ln  Oak Ridge, TN 37830‐3913  judyroitman@gmail.com  6 Jonathan Reeve From: Sent: To: Subject: trudy.stringer@everyactioncustom.com on behalf of Trudy Stringer Monday, October 14, 2019 6:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Children will be hurt.  Families will be hurt.  People will die.     Already in the bottom 10 of the 50 states and District of Columbia, the health indicators in Tennessee will plummet  should the state government be incentivised to take funds from Medicade.    Thank you for considering citizens' input.    Sincerely,  Rev. Trudy Stringer  Nashville, TN 37212  trudy.stringer@gmail.com  7 Jonathan Reeve From: Sent: To: Subject: Melissa Mitchell Monday, October 14, 2019 6:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. My son Alexander is 26. He was diagnosed at 5 months of age.  The state’s request to change TennCare’s benefits structure without federal oversight, implement a closed formulary,  and waive additional federal Medicaid requirements – coupled with the proposed block grant financing structure – could  lead to limited eligibility, decreased access to care, and reduced benefits for people with CF who rely on TennCare. I urge  you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Melissa Mitchell   315 Co Rd 41  Calhoun, TN 37309   8 Jonathan Reeve From: Sent: To: Subject: yunganny@everyactioncustom.com on behalf of Annie Middleton Monday, October 14, 2019 6:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Annie Middleton  1408 Granville Rd  Franklin, TN 37064‐2072 yunganny@comcast.net  9 Jonathan Reeve From: Sent: To: Subject: sandbox_91@everyactioncustom.com on behalf of Cheryl Pate Monday, October 14, 2019 7:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Cheryl Pate  175 Parks Ln  Pelham, TN 37366‐3404  sandbox_91@hotmail.com  10 Jonathan Reeve From: Sent: To: Subject: jeff ennis Monday, October 14, 2019 7:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   jeff ennis   north chapel road, 4340 north chapel road  Franklin, TN 37067   11 Jonathan Reeve From: Sent: To: Subject: rlinda32@everyactioncustom.com on behalf of Linda Rich Monday, October 14, 2019 7:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.   I personally have already been fighting a fight for my son. He was born stage 3 kidney disease, now at age 8 is at stage 4.  He will need a transplant at some point. We need the state to do what is right for the people. We are not just a number.  No life should be given a amount that it is worth. Linda Rich     Sincerely,  Linda Rich  2910 Goochie Ford Rd  Readyville, TN 37149‐4924 rlinda32@aol.com  12 Jonathan Reeve From: Sent: To: Subject: dsb904@everyactioncustom.com on behalf of Michael Foster Monday, October 14, 2019 7:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Michael Foster  Jonesborough, TN 37659  dsb904@gmail.com  13 Jonathan Reeve From: Sent: To: Subject: jonholland71@everyactioncustom.com on behalf of Jonathan Holland Monday, October 14, 2019 7:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Jonathan Holland  79 Tom Welch Rd  Crossville, TN 38571‐2511 jonholland71@yahoo.com  14 Jonathan Reeve From: Sent: To: Subject: jonholland71@everyactioncustom.com on behalf of Jonathan Holland Monday, October 14, 2019 7:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Jonathan Holland  79 Tom Welch Rd  Crossville, TN 38571‐2511 jonholland71@yahoo.com  15 Jonathan Reeve From: Sent: To: Subject: shannonkern@everyactioncustom.com on behalf of Shannon Kern Monday, October 14, 2019 7:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal Opposition   Dear Gabe Roberts,    Two of my family have utilized nursing home medicaid.  If they could not have obtained this there is NO WAY they would  have been able to access round the clock care.  My mother is the most current recipient of nursing home medicaid after  being septic, suffering TIA's and being hospitalized 4 months only to not be able to return to her home.  Her current  share for the nursing home is $1,499 per month.  She suffers from dementia and unable to provide for her daily needs  and requires assistance around the clock.  Being an only child I could not care for her on my own nor could a minimum of  two sitters be afforded.       She would benefit from additional services such as ongoing physical therapy ‐ she can't walk without assistance of two  CNA's; she cannot bathe herself; she requires assistance going to the bathroom.  She can barely feed herself.  When I am  able to be there I help her to eat.  She requires thickened liquids and food has to be puree thick so she hopefully does  not aspirate.  Yet I know that the insurances will not provide ongoing PT...only a certain number of visits and if no  progress it is stopped.  She sits in a recliner/lounger chair daily so her leg muscles are in atrophy...when other 71 year  olds are still going strong.  She has COPD and has had numerous rounds of pneumonia where she sits all day.  I've have  utilized hospice services twice now while she has been in care so that she gets extra support and it has helped her  though she is still weak.      In stead of taking services away, find a way to ADD SERVICES that GENUINELY HELP SENIORS!  Do a surprise visit to a  nursing home with a low score.  You'll see that people can't afford to lose services.  It's bad enough that Northeast TN  has been sold out to a medical monopoly that sues patients if they can't pay.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    16 Sincerely,  Shannon Kern  PO Box 7594  Kingsport, TN 37664‐7594  shannonkern@charter.net  17 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of Barbclinton21@gmail.com Tuesday, October 15, 2019 7:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries.  I  have grave concern about this waiver strategy, and completely appalled that the administration is willing to gamble the  needs of Tennesseans for health care, now and especially into the future, for what they think will be a short term  political win.      .    Amendment 42 is asking for an unprecedented amount of trust with too little details and no established oversight  system in place.    Respectfully,    Barbara Clinton  313 peachtree st  Nashville, TN 37210‐4925   18 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of Sidney.Schuttrow@gmail.com Tuesday, October 15, 2019 7:19 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Sidney  Schuttrow  1907 Crystal Spring Lane  Hermitage, TN 37076‐4103   19 Jonathan Reeve From: Sent: To: Subject: timmwood@everyactioncustom.com on behalf of Tim Wood Tuesday, October 15, 2019 4:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] We need better care, not less     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Please don't change Tennessee’s Medicaid partnership with the federal government  into a “block grant.”   The block grant would replace the current TennCare program. The health care of the most vulnerable Tennesseans is at  risk.   It's bad enough that some short‐sighted Tennessee lawmakers shot down the Medicaid expansion proposal that former  Gov. Bill Haslam negotiated with the federal government. That would've made health care coverage in Tennessee. This  block grant makes it worse.  Governments and the citizenry have a duty to help those of us with the least resources and the greatest health  obstacles. Tennessee needs to expand health care coverage for its citizens, not reduce it.      This waiver is flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program. We  respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tim Wood  6208 Mimi Ct  Columbia, TN 38401‐5456  timmwood@yahoo.com  20 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of fran.ansley@gmail.com Monday, October 14, 2019 11:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I write to voice my strong opposition to the recent proposal by the Division of TennCare that would convert TennCare to  a block grant program.  I know from people in my immediate family and friendship networks how difficult it is to live in  fear of losing access to adequate health insurance, let alone how difficult it is to survive without it altogether.    This new proposal, Amendment 42, if adopted, would constitute a drastic cut to TennCare at the expense of vulnerable  people with serious health care needs, and it will operate to the detriment of Tennessee's currently struggling medical  infrastructure.  Under the guise of so‐called "flexibility," this plan also promises to erode or abandon crucial protective  standards and patient safeguards.      Please reconsider this ill‐advised and inhumane plan.  At a time when hospitals are closing and hundreds of thousands of  people remain uninsured, this change will hurt both our state's people and its economy.    Respectfully,    Fran Ansley  3117 Foster Lane  Knoxville, TN 37920‐5537   21 Jonathan Reeve From: Sent: To: Subject: stopcoalcrimes@everyactioncustom.com on behalf of Bill McCabe Monday, October 14, 2019 9:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Bill McCabe  726 Clinch Mountain Rd  Eidson, TN 37731‐7420 stopcoalcrimes@gmail.com  22 Jonathan Reeve From: Sent: To: Subject: riverdoc@everyactioncustom.com on behalf of Laura Helfman Monday, October 14, 2019 8:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    This proposal is a terrible idea for doctors and patients.      I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Laura Helfman  297 Sunset Vista Rd  Coalmont, TN 37313‐7906 riverdoc@outlook.com  23 Jonathan Reeve From: Sent: To: Subject: Blake Davis Monday, October 14, 2019 8:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts:    Hello, I was born and raised in TN and have Cystic Fibrosis, a terminal disease, which is why I am writing to express my  serious concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits  structure without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements  – coupled with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care,  and reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Blake Davis   4805 Milner Dr  Nashville, TN 37211   24 Jonathan Reeve From: Sent: To: Subject: cbsspike@everyactioncustom.com on behalf of Carol Morgan Monday, October 14, 2019 7:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Why is Tennessee such a poor state?  That CHILDREN go without medical care ANYTIME is criminal.  How do any of you  sleep at night?  May God have mercy on you.   I am sure you KNOW all that is said below, but please, you have the power in this, not God.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Carol Morgan  3314 Knox Ln  Knoxville, TN 37917‐1750  cbsspike@gmail.com  25 Jonathan Reeve From: Sent: To: Subject: fhollowell@everyactioncustom.com on behalf of Faye Hollowell Monday, October 14, 2019 7:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Faye Hollowell  Cordova, TN 38016  fhollowell@comcast.net  26 Jonathan Reeve From: Sent: To: Subject: missyk45@everyactioncustom.com on behalf of SANDRA SCOTT Monday, October 14, 2019 5:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] My grandson is non verbal autistic. His dad died of cancer my daughter needs this help to pay for his medical bills which are many. than you very much for any help.     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  SANDRA SCOTT  712 Coggin Pass  Madison, TN 37115‐5416  missyk45@gmail.com  27 Jonathan Reeve From: Sent: To: Subject: Barbara Gay Monday, October 14, 2019 5:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Oppose Block Grant for TNCare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am opposed to the proposed block grant requested by the Governor and passed by the legislature. It will do nothing to  provide coverage for the 300,000 Tennesseans without health insurance or those underinsured. This grant will also allow  the state to limit medication choices and this will endanger our most vulnerable citizens.    This proposal seems to be mostly about saving the state money not providing for the health of our citizens. The block  grant would allow the state to cut services if additional funds are needed for other budget items. It asks for Tennessee  to be released from any federal oversight and accountability of the TNCare program.    I support expanding TNCare and securing the billions of dollars in federal funds that we have refused for political  reasons.  ‐‐   Barbara B. Gay, LMSW, SSWS  3910 General Bate Drive  Nashville, TN 37204    Phone: 615 297‐4145  28 Jonathan Reeve From: Sent: To: Subject: mstevens931@everyactioncustom.com on behalf of Michael Stevens Monday, October 14, 2019 5:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Michael Stevens  236 Woodson Dr  Tullahoma, TN 37388‐4126 mstevens931@lighttube.net  29 Jonathan Reeve From: Sent: To: Subject: marycamillelovely@everyactioncustom.com on behalf of Mary Camille Lovely Monday, October 14, 2019 5:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Mary Camille Lovely  1225 Drummond S  Davis, CA 95618‐4997  marycamillelovely@gmail.com  30 Jonathan Reeve From: Sent: To: Subject: cfree1005@everyactioncustom.com on behalf of Cherie Free Monday, October 14, 2019 4:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Cherie Free  1005 Morrow Rd  Knoxville, TN 37923‐1768 cfree1005@comcast.net  31 Jonathan Reeve From: Sent: To: Subject: ncmburnett@everyactioncustom.com on behalf of Nancy Burnett Monday, October 14, 2019 1:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    We need to take care of the poor children and parents unable to provide their families with adequate health care. It is  not in the best interest of taxpayers to have the drag of an unhealthy part of our populous who cannot learn and work at  their best.  I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Nancy Burnett  157 Oak Hill Cir  Sewanee, TN 37375‐2026 ncmburnett@gmail.com  32 Jonathan Reeve From: Sent: To: Subject: ginny77@everyactioncustom.com on behalf of Virginia Strubing Monday, October 14, 2019 1:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Virginia Strubing  Memphis, TN 38104  ginny77@bellsouth.net  33 Jonathan Reeve From: Sent: To: Subject: kristin@everyactioncustom.com on behalf of Kristin Ford Monday, October 14, 2019 2:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kristin Ford  Knoxville, TN 37927  kristin@kpsocialmedia.com  34 Jonathan Reeve From: Sent: To: Subject: hmstritzel@everyactioncustom.com on behalf of Helen Stritzel Monday, October 14, 2019 2:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. When I worked at Church Health in Memphis, Tennessee, i saw how the costs if  everything from vaccinations to physical therapy piled up. Citizens of Tennessee should not pay for the government  cutting costs with their children's lives. This proposal goes against the objectives of Medicaid because it gives Tennessee  new authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Helen Stritzel  Memphis, TN 38104  hmstritzel@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: glelliot1948@everyactioncustom.com on behalf of Gloria Elliot Monday, October 14, 2019 2:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Gloria Elliot  Monteagle, TN 37356  glelliot1948@gmail.com  36 Jonathan Reeve From: Sent: To: Subject: ecanahuati@everyactioncustom.com on behalf of Emi Canahuati Monday, October 14, 2019 3:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Emi Canahuati  1510 Grandview Dr  Nashville, TN 37215‐3032 ecanahuati@gmail.com  37 Jonathan Reeve From: Sent: To: Subject: Kevin Crone Monday, October 14, 2019 3:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Kevin Crone   130 Hilltop Ln  Cottontown, TN 37048   38 Jonathan Reeve From: Sent: To: Subject: lyonequas@everyactioncustom.com on behalf of Sharon Lyons Monday, October 14, 2019 3:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Sharon Lyons  250 Briar Point Rd  Allardt, TN 38504‐6047 lyonequas@msn.com  39 Jonathan Reeve From: Sent: To: Subject: lyonequas@everyactioncustom.com on behalf of Sharon Lyons Monday, October 14, 2019 3:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] ent Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Sharon Lyons  250 Briar Point Rd  Allardt, TN 38504‐6047 lyonequas@msn.com  40 Jonathan Reeve From: Sent: To: Subject: Catherine Mitchell Monday, October 14, 2019 3:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Catherine Mitchell   621 Cross Ave Unit B  Livingston, TN 38570   41 Jonathan Reeve From: Sent: To: Subject: Misty Oblak Monday, October 14, 2019 3:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Misty Oblak   Splash Pl  Murfreesboro, TN 37130   42 Jonathan Reeve From: Sent: To: Subject: John Chase Monday, October 14, 2019 3:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   John Chase   109 N Main St  Memphis, TN 38103   43 Jonathan Reeve From: Sent: To: Subject: eaglesfanintn@everyactioncustom.com on behalf of SCOTT SMITH Monday, October 14, 2019 3:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    We need real healthcare reform in this country and this state, and Governor Lee's horrible plan isn't it.    Sincerely,  Mr. SCOTT SMITH  9 Elliott Cir  Mount Juliet, TN 37122‐4433 eaglesfanintn@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: jshrago@everyactioncustom.com on behalf of Jackie Shrago Monday, October 14, 2019 4:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Medicaid Block Grant Proposal   Dear Gabe Roberts,    This is a very challenging proposal to implement.  There may be some ways in which the savings from such a proposal  could be used to expand to additional people.  We all know in TN that there are hundreds of thousands who need and  want health care and have no access to get it, since they fall into the 'gap' of not being eligible for the detailed and  complex rules of current Medicaid eligibility.    We all know that if TN had chosen to Expand Medicaid, most of these folks would have been covered.  This program has  proven in many other states, including our neighbor Kentucky to be providing better health outcomes for people ‐‐and  many of those people being able to work, while they are not able to do so now, due to health issues.    The TennCare program has been severely challenged and finally succeeded in developing a very important capability to  allow on‐line access to enrolling in TennCare and many TennCare eligible adults and their children are able to apply and  gain access and keep their information updated.  It has taken several years to refine that process and make it truly work  for a large portion of the TennCare eligible people.    TennCare has streamlined its administrative costs with this new online system and the ease with which many of the  eligible people are able to upload key documents to provide their eligibility within the detailed rules.  But we are still  avoiding facing the challenge of the hundreds of thousands who do not have care‐‐except the most expensive type of  TennCare services through an hospital emergency room.  It however takes help from volunteers to get started.  There is  no way for them to find out about the new functionality on their own, so they often go without care until the most  expensive emergency care is needed.      Why are we changing a reasonably KNOWN and now more systematic system for a completely UNKNOWN and new  system likely requiring 3 to 4 more years of upheaval and confusion among those who are eligible, and still not doing  anything for the population who are not eligible.  We will lose the progress we have made in lowering Emergency Rm  costs and getting up‐to‐date information on a totally new system.     TennCare needs more stability, not less. We do not need to return to the days when managed care contractors failed in  patient care delivery or in paying bills of patients and providers. This untried and extensive new system threatens the  availability of vital health coverage for 1 million Tennesseans eligible for caretaker and children coverage.     I urge you to test the results of only a small sample of people both in administrative time, cost, effort and document  how coverage is not avoided or cancelled while a new process is tired.  I further urge you to measure the lack of  coverage for eligible people if the new system is applied to 1 million people. Trying new things may be helpful, and if  done slowly and correctly, perhaps we can all learn.  Trying it all at once is bound to cost lives and many dollars that  would otherwise be spent on provider‐delivered health care.    Sincerely,  Jackie Shrago  3604 Woodmont Blvd  Nashville, TN 37215‐1828 jshrago@comcast.net  45 Jonathan Reeve From: Sent: To: Subject: carorossini@everyactioncustom.com on behalf of Caroline Rossini Monday, October 14, 2019 3:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Caroline Rossini  Nashville, TN 37204  carorossini@gmail.com  46 Jonathan Reeve From: Sent: To: Subject: Linda DeWitt Monday, October 14, 2019 3:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Linda DeWitt   497 Brown Bluff Ln  Sugar Tree, TN 38380   47 Jonathan Reeve From: Sent: To: Subject: sandrafrice55@everyactioncustom.com on behalf of Sandra Rkce Monday, October 14, 2019 3:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Expand Medicaid .  Don't try an experiment with people's lives!    Sincerely,  Ms Sandra Rkce  Sewanee, TN 37375  sandrafrice55@icloud.com  48 Jonathan Reeve From: Sent: To: Subject: lorirclemons@everyactioncustom.com on behalf of Lori Clemons Monday, October 14, 2019 3:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lori Clemons  2534 Tapestry St  Thompsons Station, TN 37179‐5454 lorirclemons@gmail.com  49 Jonathan Reeve From: Sent: To: Subject: jamercer@everyactioncustom.com on behalf of Rebecca Mercer Monday, October 14, 2019 3:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    My sister has a disability.  My daughter has a genetic illness.  I am therefore opposed to the proposal to radically change  Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into a “block  grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rebecca Mercer  Memphis, TN 38104  jamercer@bellsouth.net  50 Jonathan Reeve From: Sent: To: Subject: karenmetharp@everyactioncustom.com on behalf of Karen Tharp Monday, October 14, 2019 3:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  the vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee  new authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. The proposal would give Tennessee new  authority to cut services for children, low‐income parents, and people with disabilities.    I am an RN and see every day how not expanding Medicaid has hurt Tennesseans and our rural hospitals.  This is all  politics and none of the governing that the Tennessee people need and should expect from their elected officials.  Please  do the right thing for your constituents and vote against this TennCare block grant and expand Medicaid.    Sincerely,  Ms. Karen Tharp  94 Bobtown Cir  Sewanee, TN 37375‐2128  karenmetharp@gmail.com  51 Jonathan Reeve From: Sent: To: Subject: phamorsky2002@everyactioncustom.com on behalf of Pamela Hamorsky Monday, October 14, 2019 3:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Pamela Hamorsky  Spring Hill, TN 37174  phamorsky2002@yahoo.com  52 Jonathan Reeve From: Sent: To: Subject: vlagems@everyactioncustom.com on behalf of Vicki Atkinson Monday, October 14, 2019 3:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I DON'T WANT TO DIE JUST CAUSE I'M CHRONICALLY ILL   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.I    I worked as a Tenn. State employee for 7 years and FL. State for 13 years.   I paid my taxes which were to be used for future needs and services.  I'm now chronically ill and disabled. Please don't allow something that will kill me and many others.    Think about what serves the people not what serves politicians.  Thank you    Sincerely,  Ms. Vicki Atkinson  803 Meadows Dr  Lebanon, TN 37087‐4941  vlagems@hotmail.com  53 Jonathan Reeve From: Sent: To: Subject: rchman@everyactioncustom.com on behalf of Jim Rich Monday, October 14, 2019 3:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    It took me quite awhile to get the TennCare benefit. Without it, I would have some serious challenges. I get a very small  SS check and before TennCare, most of my check was eaten up with drug costs. Be nice if you left this vital program  alone.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jim Rich  158 Vulco Dr  Hendersonville, TN 37075‐4820 rchman@comcast.net  54 Jonathan Reeve From: Sent: To: Subject: alkoehler6@everyactioncustom.com on behalf of Allison Koehler Monday, October 14, 2019 3:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Allison Koehler  2414 Mcintyre Ct  Franklin, TN 37069‐6953 alkoehler6@gmail.com  55 Jonathan Reeve From: Sent: To: Subject: Glenda Johnston Monday, October 14, 2019 4:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Glenda Johnston   1600 Clearview Dr  Brentwood, TN 37027   56 Jonathan Reeve From: Sent: To: Subject: rorlowske@everyactioncustom.com on behalf of Veronica Bourassa Monday, October 14, 2019 4:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Veronica Bourassa  8429 Back Valley Rd  Evensville, TN 37332‐3269 rorlowske@gmail.com  57 Jonathan Reeve From: Sent: To: Subject: hiortdahl@everyactioncustom.com on behalf of Sandra Hiortdahl Monday, October 14, 2019 4:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a handicapped person who nonetheless has a full time job with benefits, I nonetheless feel very deeply for those who  need medicaid and medicare and otherwise cannot get help. It is shameful to let people suffer. I am sure Jesus would  not approve of cutting services to those in need. What will He say when you get there and He asks you how well you  took care of people? Do you think it will matter if you tell Him that you cut services to many needy people because a few  people took advantage of the system? There are better ways to fix the problems here, so please think this over carefully.  ‐‐Dr. Sandy Hiortdahl      THEREFORE:   I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Sandra Hiortdahl    Sincerely,  Dr. Sandra Hiortdahl  217 W H St  Elizabethton, TN 37643‐3119  hiortdahl@gmail.com  58 Jonathan Reeve From: Sent: To: Subject: bbmathieson@everyactioncustom.com on behalf of Barbara Mathieson Monday, October 14, 2019 4:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Barbara Mathieson  2115 Yeaman Pl  Nashville, TN 37206‐4230 bbmathieson@gmail.com  59 Jonathan Reeve From: Sent: To: Subject: Joye Martin Monday, October 14, 2019 4:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Joye Martin   5202 Towhee Cove  Memphis, TN 38134   60 Jonathan Reeve From: Sent: To: Subject: lisa37027@everyactioncustom.com on behalf of Lisa Headley Monday, October 14, 2019 4:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lisa Headley  624 Split Rail Dr  Brentwood, TN 37027‐5737 lisa37027@aol.com  61 Jonathan Reeve From: Sent: To: Subject: warreng58@everyactioncustom.com on behalf of Grady Warren Monday, October 14, 2019 4:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Grady Warren  317 May St  Lawrenceburg, TN 38464‐2526  warreng58@yahoo.com  62 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of jsfavours@gmail.com Monday, October 14, 2019 4:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Jacquelyn Favours  2335 Benay Rd  Nashville, TN 37214‐1164   63 Jonathan Reeve From: Sent: To: Subject: kminault@everyactioncustom.com on behalf of Kent Minault Monday, October 14, 2019 3:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Kent Minault  311 W Glenwood Ave  Knoxville, TN 37917‐5601 kminault@gmail.com  64 Jonathan Reeve From: Sent: To: Subject: James Taylor Monday, October 14, 2019 3:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   James Taylor   1904 Long Ave  Nashville, TN 37206   65 Jonathan Reeve From: Sent: To: Subject: aef03@everyactioncustom.com on behalf of Adrienne Frey Monday, October 14, 2019 3:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Adrienne Frey  403 Stable Dr  Franklin, TN 37069‐4138  aef03@bellsouth.net  66 Jonathan Reeve From: Sent: To: Subject: brownezell04@everyactioncustom.com on behalf of Julie Brown Monday, October 14, 2019 3:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Vote NO on the Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. I have family members depending on these funds to live healthy lives. Everyone  deserves good health regardless of their income.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Julie Brown  Chattanooga, TN 37421  brownezell04@gmail.com  67 Jonathan Reeve From: Sent: To: Subject: Laleh Bahrami Monday, October 14, 2019 3:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am submitting comments for the Medical block grant proposal.    As a pediatrician, I know that children are the most vulnerable members of our society; and yet they are the most  important, because they will be our future leaders, our future Senators, our future doctors.  All of these children deserve the same high‐quality care, no matter the family's income. The current Medicaid block  grant proposal will disproportionately affect children from low‐income families.   I am concerned by a few features of this proposal. Firstly, it assumes that all beneficiaries will maintain the current level  of need over the course of the waiver. However, there could be a situation (or several) that leads to a need for  additional federal funds. The current proposal does not account for this.  I also want to make sure there is a section of the proposal that commits to keeping EPSDT at the current level. As you  know, EPSDT helps ensure we prevent chronic diseases that would otherwise be a burden on our healthcare system.  Finally, the proposed, restricted formulary would limit access to medically‐indicated medications. This will cause undue  harm to our low‐income children.    Please consider the health and wellness of children. Thank you.    Laleh Bahrami, MD, FAAP  68 Jonathan Reeve From: Sent: To: Subject: Kathleen Cimino Monday, October 14, 2019 3:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerns with Tennessee's 1115 Waiver Request   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Director Roberts:    As a resident of Tennessee and someone personally affected by cystic fibrosis (CF), I am writing to express my serious  concerns with Tennessee’s 1115 Demonstration Waiver. The state’s request to change TennCare’s benefits structure  without federal oversight, implement a closed formulary, and waive additional federal Medicaid requirements – coupled  with the proposed block grant financing structure – could lead to limited eligibility, decreased access to care, and  reduced benefits for people with CF who rely on TennCare. I urge you to reconsider.     For many individuals with cystic fibrosis, TennCare serves as a payer of last resort by filling gaps left by private health  plans. Instituting the proposed block grant would limit the federal funds provided to TennCare. I am concerned that this  could ultimately force the state to constrain eligibility, reduce benefits, lower provider payments, or increase cost‐ sharing. Specifically, for patients with serious chronic conditions like cystic fibrosis, such cuts could mean Medicaid no  longer covers the complex, specialized care they need. Lack of proper care could lead to an increase in hospitalizations,  decrease in lung function, or decrease in body mass index – all dire consequences for someone with cystic fibrosis.     I am also concerned with the waiver’s inclusion of a closed formulary, which has the potential to limit access to critical  medications for people with CF. The state proposes to base coverage decisions for prescription drugs on a cost‐ effectiveness review. However, current reviews are often based on limited evidence and incorporate little data on  patient experiences. I urge the state to abandon this proposal.     Further, I urge the state to reconsider its request to limit federal oversight of changes to TennCare’s benefits package  and to waive federal managed care requirements. Individuals with CF who are eligible for TennCare must be able to  receive the treatment and services that are necessary for their care and must be able to rely on the protections and  standards for Medicaid managed care organizations.     This proposal would do grave harm for people with cystic fibrosis who rely on TennCare to receive their care. I urge you  to reconsider the block grant funding structure and to abandon the proposed closed formulary, flexible benefit  structure, and waived managed care oversight provisions.    Sincerely,   Kathleen Cimino   3925 Chickamauga Ave  Chattanooga, TN 37406   69 Jonathan Reeve From: Sent: To: Subject: Jessica S. Fox Monday, October 14, 2019 3:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] PUBLIC COMMENT BLOCK GRANT   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***     My name is Jessica Fox, and I live in Johnson City, TN. I’m a mom to 3 amazing children. Claire is my 5  year old middle child. She loves music and playing dress up. But, Claire was also born with Cri Du Chat  Syndrome, a chromosomal deficiency that has caused multiple dangerous heart defects. She flew by  aircraft 5 hours from our home to have open heart surgery at 4 days old. She has required continuous  care from the day she was born. She has a feeding tube that she receives all her nutrition through. She  has endured numerous surgeries, invasive medical procedures, and banked many hours of therapy in  her short life.     Claire has always been covered by my employer’s health insurance. In addition, due to her extended  hospitalization, we also qualified for TennCare as a secondary policy. This was necessary because as  great as my insurance was, it did not cover everything Claire needed, like her therapies, medical  equipment, and surgeries.     Just prior to Claires 4th birthday, we lost her TennCare without warning, because we no longer qualified.  During the last legislative session, we were able to get a Katie Beckett waiver passed in Tennessee. I  finally saw some hope and felt relief. Now, with the suggestions of Block Grants, I feel the target is back  on my child.     A Block Grant will put a limit on dollars. It will mean that the funding that is allocated to provide nursing  care to Claire at school may be affected. It will mean that her speech, occupational, and physical  therapies will once again be ripped away. These are life saving treatments. I firmly stand against Block  Grants for Medicaid and the lack of integrity and oversight it will certainly bring.    Sent from my iPhone  70 Jonathan Reeve From: Sent: To: Subject: sc1@everyactioncustom.com on behalf of Rebecca Cummings Monday, October 14, 2019 8:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.  It will threaten the viability of our rural hospitals.      How can limiting the amount of money we can receive possibly improve our outcomes?  Pursuing innovative approaches  is a great idea, but is better done by allowing limited scope trials to test them out rather then simply shutting off all  federal oversight.  We must not balance our federal budget on the backs of the poor while the super wealthy pay fewer  and fewer taxes.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Rebecca Cummings  119 Poplar Rd  Unicoi, TN 37692‐6625  sc1@stout‐cummings.net  71 Jonathan Reeve From: Sent: To: Subject: kira.a.benton@everyactioncustom.com on behalf of Kira Benton Monday, October 14, 2019 9:35 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kira Benton  606 Watts Cir  Nashville, TN 37209‐4426  kira.a.benton@vanderbilt.edu  72 Jonathan Reeve From: Sent: To: Subject: svggrl@everyactioncustom.com on behalf of Danielle Knowles Monday, October 14, 2019 9:44 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Danielle Knowles  Chattanooga, TN 37402  svggrl@gmail.com  73 Jonathan Reeve From: Sent: To: Subject: rotarygirl@everyactioncustom.com on behalf of Beverly White Monday, October 14, 2019 9:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. I have lived and worked in TN for most of my life, this is where I will spend the rest  of my life, and I need TennCare to be there for me.     I am disabled and I need the care and services that TennCare provides. I am on insulin and other drugs, and my Social  Security check isn't big enough to pay out of pocket. TennCare is keeping me alive, by giving me Extra Help on  medications.     I am able to see the doctors and specialists I need. All Tennesseans deserve medical care and accepting this block grant  will hurt and harm so many, including me.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Beverly White  3553 Galloway Ave  Memphis, TN 38122‐5100 rotarygirl@gmail.com  74 Jonathan Reeve From: Sent: To: Subject: rdwilliams1950@everyactioncustom.com on behalf of Robert Williams Monday, October 14, 2019 9:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] No to the Block Grant Proposal!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Robert Williams  129 Overbriar Dr NE  Cleveland, TN 37312‐5453 rdwilliams1950@live.com  75 Jonathan Reeve From: Sent: To: Subject: shrebekawn@everyactioncustom.com on behalf of Rebekah Brown Monday, October 14, 2019 9:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose Medicaid Block Grant Proposal   Dear Gabe Roberts,    Please do not go forward with the proposal for the Medicaid Block Grant. My family is covered by TennCare and it helps  us so much. We would not have access to health care‐ we would be in debt every time we had a health cost if we did not  have TennCare. This proposal would be detrimental to our family as it jeopardizes TennCare . Also TennCare needs more  accountability not less.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rebekah Brown  Nashville, TN 37211  shrebekawn@gmail.com  76 Jonathan Reeve From: Sent: To: Subject: jmvitek@everyactioncustom.com on behalf of John Vitek Monday, October 14, 2019 9:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.  This is especially true for women's health care issues.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  John Vitek  866 W Outer Dr  Oak Ridge, TN 37830‐8314 jmvitek@comcast.net  77 Jonathan Reeve From: Sent: To: Subject: thedance51@everyactioncustom.com on behalf of Ken Stayton Monday, October 14, 2019 10:06 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     Too many hospitals in Tennessee (especially rural) have been shut down due to this state refusing to adequately fund  healthcare and to meet the needs of its citizens.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Ken Stayton  1009 Fairwin Ave  Nashville, TN 37216‐3616 thedance51@comcast.net  78 Jonathan Reeve From: Sent: To: Subject: mscearonson@everyactioncustom.com on behalf of Carolyn Aronson Monday, October 14, 2019 10:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I am retired and live in one of the poorest counties in TN.  For six years I was a volunteer Medicare counselor for the  county and met with many people trying to survive on meager Social Security payments because they had worked  diligently all their adult lives in sweatshops that only raised their pay because the federal minimum wage increased.   There are too many people who do not today qualify for Tenn Care and many children in the county who have been  kicked off because the State did not help parents to understand the process of renewing their health insurance.  Many  here are illiterate or, at best, poor readers.  They are suffering at the hands of both the federal and the state  governments.  Block granting their health care will only serve to make matters worse.    Sincerely,  Ms. Carolyn Aronson  127 Legacy Ln  Jamestown, TN 38556‐1107  mscearonson@gmail.com  79 Jonathan Reeve From: Sent: To: Subject: Brady Etzkorn-Morris Monday, October 14, 2019 10:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal Dear TennCare Public Comment,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Brady Etzkorn‐Morris  2008 Owen St  Nashville, TN 37208  80 Jonathan Reeve From: Sent: To: Subject: dustybarn47@everyactioncustom.com on behalf of Sandy brendel Monday, October 14, 2019 10:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Sandy brendel  3026 Banner Springs Rd  Jamestown, TN 38556‐5021 dustybarn47@yahoo.com  81 Jonathan Reeve From: Sent: To: Subject: mharmo18@everyactioncustom.com on behalf of Makayla Harmon Monday, October 14, 2019 10:42 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Makayla Harmon  1701 Forest Ave Apt 214 Knoxville, TN 37916‐1331 mharmo18@vols.utk.edu  82 Jonathan Reeve From: Sent: To: Subject: zxilana@everyactioncustom.com on behalf of Tara Gifford Monday, October 14, 2019 10:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I do not support Medicaid Block Grant Proposal   Dear Gabe Roberts,    I do not support the change in Tennessee’s Medicaid set up by converting federal funding for TennCare into a “block  grant.” A change of this magnitude would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. To help the people who need help the most.     This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these  vulnerable populations. The state could eliminate or restrict services like physical therapy, hospice, and transplant  coverage without normal federal oversight – and arbitrarily limit who gets them.     The proposal could also cut back on core health care services like hospital care, without federal approval or public  notice, and exclude coverage of the most effective prescription drugs. As more and more people in TN lose access to  hospitals and healthcare, taking steps that would increase the number of residents who lose access to medical care is  morally indefensible.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Tara Gifford  5601 Browntown Rd  Chattanooga, TN 37415‐1240 zxilana@gmail.com  83 Jonathan Reeve From: Sent: To: Subject: lachana316@everyactioncustom.com on behalf of Ellen Nelson Monday, October 14, 2019 11:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I am against starting block grant Medicaid   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Although I am retired and use Medicare, I often hire people to work on my  property.  Right now, I have a young married  man with a 2 year old son.   He works hard and earns a low wage consistently; not enough earnings to pay for private  health insurance or pay out of his own pocket for medical expenses  Who does have enough to pay out of pocket for  expensive care?)  The son was born prematurely and has several serious preexisting  conditions, including chronic iron deficiency and a  weak immune system. Losing Mason’s Tenncare at the whim of Tennessee politicians would be devastating to this young  family and result in the child’s death!    I would gladly pay higher taxes to support families like this one!    Sincerely,  Ellen Nelson  1410 Nichol Creek Dr  Jamestown, TN 38556‐1018 lachana316@aol.com  84 Jonathan Reeve From: Sent: To: Subject: jrt.enterprises@everyactioncustom.com on behalf of Michael Spencer Monday, October 14, 2019 11:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mx. Michael Spencer  409 Terry Pl  Hermitage, TN 37076‐2128  jrt.enterprises@yahoo.com  85 Jonathan Reeve From: Sent: To: Subject: ctodd@everyactioncustom.com on behalf of Christine Todd Monday, October 14, 2019 11:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Please rethink the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Christine Todd  102 N 2nd St  Memphis, TN 38103‐2203  ctodd@calvarymemphis.org  86 Jonathan Reeve From: Sent: To: Subject: a.poulton@everyactioncustom.com on behalf of Anita Poulton Monday, October 14, 2019 11:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a grandmother to two children with disabilities.  I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This   is completely the wrong thing to do.      The  governor has said the public doesn't understand "block grants. "People that have TennCare are informed." I believe  he is uninformed about the ramifications of "block grant" funding.  This is their insurance and the only thing that keeps  some vulnerable Tennesseans from financial ruin.    If the governor really wants cares and serve Tennesseans.  He would stop this proposal and expand Medicaid!!  All  Tennesseans need and deserve vital heathcare coverage.    Why won't the governor listen to the people.  He scheduled town hall meetings but never attended.  That tells you  someone else has his ear not the poor and needy.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I  respectfully urge you not to go forward with this harmful proposal.    Sincerely,      Anita Poulton, RN, BSN    Phone: 615‐859‐0080    Sincerely,  Anita Poulton  1833 Fox Chase Dr  Goodlettsville, TN 37072‐4222 a.poulton@comcast.net  87 Jonathan Reeve From: Sent: To: Subject: pelaynep@everyactioncustom.com on behalf of P Elayne Poston Monday, October 14, 2019 11:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  P Elayne Poston  3879 Lost Shadows Cv  Memphis, TN 38128‐2416 pelaynep@gmail.com  88 Jonathan Reeve From: Sent: To: Subject: mcmullen1@everyactioncustom.com on behalf of W.McMullen Monday, October 14, 2019 11:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  W. McMullen  8348 Colton Cv  Germantown, TN 38139‐3249 mcmullen1@aol.com  89 Jonathan Reeve From: Sent: To: Subject: susanhathcock@everyactioncustom.com on behalf of Susan Hathcock Monday, October 14, 2019 10:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    How cruel, how unChristian, how unAmerican.  As the director, for many years, of a small public library that served  many poor and disadvantaged Tennesseans, I saw first hand the difference a secure Medicaid program made in their  lives.  I also saw their great fear of losing their coverage.  What you are doing will turn many I’ll and struggling citizens of  our state into beggars in their own country.  It is shameful, it is callous, and your decision will not be forgotten——or  forgiven.    Sincerely,  Mrs. Susan Hathcock  303 E 2nd Ave  Lenoir City, TN 37771‐2511 susanhathcock@gmail.com  90 Jonathan Reeve From: Sent: To: Subject: heflinca@everyactioncustom.com on behalf of Craig Anne Heflinger Monday, October 14, 2019 9:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Dear TennCare and State of Tennessee officials,    I am writing to oppose the proposal to turn TennCare into a Block Grant because I believe it will weaken Tennessee’s  already unstable health care system.  TennCare is critical for so many children and adults across Tennessee. It provides  comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with  mental illness, many of whom rely on it to access essential health treatments and manage their condition.      I have conducted health services research describing TennCare’s important role and have helped document how it  allows access to needed physical and health care.   TennCare is especially critical for maintaining access to rural children  and their families.  The families we interviewed stressed how, without TennCare, their children would not receive the  services or medication that they needed to be able to stay in their own communities and go to their neighborhood  schools instead of rely on hospital treatment.  We still have children in Tennessee who are placed in State Custody to be  able to access care that is unavailable to them in their communities.     I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal  would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this  proposal would allow the state to eliminate or restrict services that are important to people with mental illness. This  joint state‐federal program has benefitted from federal oversight and federal mandates that insure a comprehensive set  of services with quality assurance oversight.     More people need access to TennCare, not less.      I respectfully urge you to reconsider this proposal and focus on solutions that help vulnerable Tennessee children and  adults, not hurt them.       Sincerely,  Dr. Craig Anne Heflinger  120 Lakeside Dr  Goodlettsville, TN 37072‐9126 heflinca@gmail.com  91 Jonathan Reeve From: Sent: To: Subject: cchamjones@everyactioncustom.com on behalf of Carolyn Jones Monday, October 14, 2019 9:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Strongly Oppose Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Carolyn Jones  600 N Jefferson St  Winchester, TN 37398‐1336 cchamjones@aol.com  92 Jonathan Reeve From: Sent: To: Subject: Mary Davis Monday, October 14, 2019 9:01 AM PUBLICE NOTICE TENNCARE [EXTERNAL]   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, TennCare is important to me and the clients I serve. It provides comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare has helped my clients by allowing them to live in 24/7 supervised housing due to their several mental illnesses. The clients I currently work with can not take care of themselves. Many need assistance with medications, they would forget to take them or possibly take too much causing other adverse reactions. Without TennCare they would lose this housing they so desperately need. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely,  Mary Davis, BS Life Skills Educator/Care Manager Volunteer Behavioral Health Care Services 93 Jonathan Reeve From: Sent: To: Subject: schlacter9@everyactioncustom.com on behalf of Michael Schlacter Monday, October 14, 2019 8:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,        Block Grant Proposal, No!    Why would Tennessee cut $2 billion from TennCare when; Tennessee has closed 12 Rural Hospitals, has 675,000  uninsured which includes 425,000 Children; Tennessee is one of nine states to see an increase in the number of Children  that have become uninsured in 2018; there is an increasing number of Seniors needing long‐term care?    The Block Grant Proposal allows cuts of $2 billion from TennCare funds by actions such as; restricting or eliminating  physical therapy, hospice, and medicines without normal oversight; cuts back core services like hospital care and  emergency services      without federal approval or public notice, and excludes coverage of some important prescription  drugs.             The Block Grand Proposal is simply a transfer of money from the patients and providers to Tennessee and Federal  Governments.    One more note; Tennessee is at the bottom of health measurements such as Infant Mortality, Maternal Mortality and  Life Expectancy.      Sincerely,  Mr. Michael Schlacter  6037 Brentwood Chase Dr  Brentwood, TN 37027‐4449 schlacter9@gmail.com  94 Jonathan Reeve From: Sent: To: Subject: mary.elaine.hanna@everyactioncustom.com on behalf of Mary Hanna Sunday, October 13, 2019 4:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mary Hanna  Nashville, TN 37217  mary.elaine.hanna@vanderbilt.edu  95 Jonathan Reeve From: Sent: To: Subject: phillip.vest@everyactioncustom.com on behalf of Phillip Vest Sunday, October 13, 2019 5:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Phillip Vest  821 Stirrup Dr  Nashville, TN 37221‐1918 phillip.vest@gmail.com  96 Jonathan Reeve From: Sent: To: Subject: rileEcoyote@everyactioncustom.com on behalf of Kevin Riley Sunday, October 13, 2019 6:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kevin Riley  97 White Bridge Rd Apt BS Nashville, TN 37205‐1425 rileEcoyote@tutanota.com  97 Jonathan Reeve From: Sent: To: Subject: vgrisham56@everyactioncustom.com on behalf of Vickie Grisham Sunday, October 13, 2019 7:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I and my family oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.       TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Vickie Grisham  2999 Majesty Dr  Murfreesboro, TN 37129‐2815 vgrisham56@gmail.com  98 Jonathan Reeve From: Sent: To: Subject: marycamillelovely@everyactioncustom.com on behalf of Mary Camille Lovely Sunday, October 13, 2019 12:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mary Camille Lovely  38102  marycamillelovely@gmail.com  99 Jonathan Reeve From: Sent: To: Subject: tptuley@everyactioncustom.com on behalf of Therese Tuley Sunday, October 13, 2019 12:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Dear Mr. Gabe Roberts,    While I am not a Medicaid recipient, I am writing to you as a Tennessee citizen, a voter, and a taxpayer,  I am opposed to  the proposal to change Tennessee’s Medicaid partnership with the federal government by converting federal funding for  TennCare into a block grant.    Here are some of the reasons why:    1.The state could eliminate or restrict services like physical therapy, hospice, and transplant coverage without normal  federal oversight and arbitrarily limit who gets them.     2.The proposal could exclude coverage of the most effective prescription drugs for a patient.While I am not on  Medicaid, I  have had a prescription drug dropped from my formulary two times. I then had to look for another  comparable drug which costs much more money. It was a stressful situation for me, and I can only imagine how awful it  would be for a family with a lower income.    3.Given the unfortunate record of mistakes that have been made by TennCare (cutting off aid to 200K children who  were still eligible and TN seniors having money erroneously taken out of their Social Security checks), it does not inspire  confidence and trust to think how a block grant would be managed. This proposal also unfortunately invites fraud and  abuse.      4.Medicaid block grants are illegal and will be challenged in court‐‐a waste of of money,, time, and other resources.    To me, one sign of a good government is one which decently cares for children, people with disabilities, and people of  limited income. Not only for these citizens themselves, but for the good of the whole state and country. A healthy  citizenry is a good thing for the state's and country's economy.       I respectfully ask you not to go forward with this proposal.    Sincerely,    Therese P. Tuley  1005 E Dallas Rd  Chattanooga, TN 37405    Sincerely,  Ms. Therese Tuley  1005 E Dallas Rd  Chattanooga, TN 37405‐2208 tptuley@gmail.com  100 Jonathan Reeve From: Sent: To: Subject: molly.harwood@everyactioncustom.com on behalf of Molly Harwood Sunday, October 13, 2019 1:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a legal volunteer at a free medical clinic in Nashville, I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans, who already struggle to  ensure their medical needs are met. We have clients who drive three hours to come to out clinic because there are so  few free medical clinics in the state that this is their only option.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Molly Harwood  2517 Fairfax Ave  Nashville, TN 37212‐3404 molly.harwood@gmail.com  101 Jonathan Reeve From: Sent: To: Subject: stephanie.barca@everyactioncustom.com on behalf of Stephanie Barca Sunday, October 13, 2019 1:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Stephanie Barca  Nashville, TN 37209  stephanie.barca@gmail.com  102 Jonathan Reeve From: Sent: To: Subject: starlashaw1747@everyactioncustom.com on behalf of Starla Shaw Sunday, October 13, 2019 12:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Starla Shaw  2385 Blanton Rd  Adamsville, TN 38310‐5011 starlashaw1747@yahoo.com  103 Jonathan Reeve From: Sent: To: Subject: dfoster552@everyactioncustom.com on behalf of Donna Foster Sunday, October 13, 2019 1:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] My husband is dying of congestive heart failure. We have sold everything but our house and spent every spare dime for medical bills and medication .   Dear Gabe Roberts,    Medicaid is too narrow in scope as it is. There is no good reason not to EXPAND Medicaid and accept all the Federal  monies available to help more poor and elderly people. It would also save our rural hospitals from closure.   I am  opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Donna Foster  334 Ross Ln  Winfield, TN 37892‐2272  dfoster552@yahoo.com  104 Jonathan Reeve From: Sent: To: Subject: Paul.bienhoff@everyactioncustom.com on behalf of Paul Bienhoff Sunday, October 13, 2019 2:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     May you never be poor or without food health care. In the meantime, please stop assaulting those who are. And that  means ‐ stop threatening your fellow citizens!    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Paul Bienhoff  Kingsport, TN 37663  Paul.bienhoff@gmail.com  105 Jonathan Reeve From: Sent: To: Subject: saraha72724@everyactioncustom.com on behalf of Sarah Anderson Sunday, October 13, 2019 3:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Sarah Anderson  111 17th Ave S  Nashville, TN 37203‐2700 saraha72724@gmail.com  106 Jonathan Reeve From: Sent: To: Subject: donnapatroni@everyactioncustom.com on behalf of Donna Patroni Sunday, October 13, 2019 6:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Objections to Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.”     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. In other words, it was created as a safety net for people whose voices aren’t often  heard in political circles.  Until you find yourself in a job that doesn’t pay enough to cover the rent, you have no business  giving politicians (who rarely have this experience) the power to adjust the terms of access to medical care.  Until you  are a pregnant woman who knows she does not have the economic or emotional resources to bring a child into the  world, you should not give politicians the potential to create obstacles to a safe, legal abortion.    The state should not be allowed to make changes to the Medicaid program without federal oversight or eliminate  federal standards, which are in place for the protection of patients.     I respectfully urge you not to go forward with this proposal.    Sincerely.  Donna Patroni  Middle school teacher, former child care worker, restaurant server, DHS Family Assistance worker, library assistant    Sincerely,  Donna Patroni  3809 Boogertown Rd  Sevierville, TN 37876‐9001 donnapatroni@gmail.com  1 Jonathan Reeve From: Sent: To: Subject: kelmmir@everyactioncustom.com on behalf of Miriam Kelmers Sunday, October 13, 2019 7:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miriam Kelmers  116 Blue Ridge Ct  Oak Ridge, TN 37830‐7678 kelmmir@icloud.com  2 Jonathan Reeve From: Sent: To: Subject: cdotylaw@everyactioncustom.com on behalf of Caitlin Smith Sunday, October 13, 2019 8:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Caitlin Smith  146 Ervin St  Hendersonville, TN 37075‐3918 cdotylaw@gmail.com  3 Jonathan Reeve From: Sent: To: Subject: tanyatull@everyactioncustom.com on behalf of Tanya Tull Sunday, October 13, 2019 9:44 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Please vote no to Medicaid Block Grant   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tanya Tull  895 Pickwick St  Savannah, TN 38372‐3055 tanyatull@icloud.com  4 Jonathan Reeve From: Sent: To: Subject: smaemccune85@everyactioncustom.com on behalf of Sandra McCune Sunday, October 13, 2019 10:23 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I retired after 40 years of practice as a registered nurse. I have seen innumerable cases where patients health was  compromised due to inability to access Medicaid, or inadequate Medicaid benefits. These shortsighted policies end up  costing more in the end, because when they finally get treatment, they are much sicker. I am opposed to the proposal to  radically change Tennessee’s Medicaid partnership with the federal government by converting federal funding for  TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable  Tennesseans. Women are especially vulnerable, and this proposal feels like another attempt to prevent access to  reproductive health care.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sandra McCune  Dunlap, TN 37327  smaemccune85@pm.me  5 Jonathan Reeve From: Sent: To: Subject: bburns07@everyactioncustom.com on behalf of Vikki Burns Saturday, October 12, 2019 8:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     As an educator in our public high schools, I see the results of the lack of access to affordable and convenient healthcare  options for our students and their families. I do not see how this action to change the administration of TennCare will  better serve our families with children who cannot afford health care even though one or both parents may be working.  This change would impact our students' health and their ability to receive adequate medical care in our communities,  which in many areas are already underserved.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Vikki Burns  306 Hilltop Cir  Caryville, TN 37714‐3110 bburns07@comcast.net  6 Jonathan Reeve From: Sent: To: Subject: fooj171989@everyactioncustom.com on behalf of Francis Offiong Saturday, October 12, 2019 11:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to this proposal that will  radically change Tennessee’s Medicaid partnership with the federal government  by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and  jeopardize coverage for vulnerable Tennesseans. In addition, grants always have a tendency to run out. When that  happens, what will be the end result? Human sufferings and devastations to prevail is a bad proposal for the great state  of TN. With the overwhelming demands and needs for Medicaid, block grant proposal is a flawlessly poor idea. Let us  not waste precious time to fix what is NOT broken but invest in innovative ways and engagements for process  improvements.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Francis Offiong  8769 Lybrook Cv W  Cordova, TN 38016‐1499 fooj171989@gmail.com  7 Jonathan Reeve From: Sent: To: Subject: mr.ulamog@everyactioncustom.com on behalf of J Garland Saturday, October 12, 2019 4:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] No Block Grant!!!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans, especially those with a chronic illness, like me.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal, many people will die and others will continue to  go bankrupt due to medical bills. Tennesseeans do not want or need their healthcare compromised, which is exactly  what the block grant proposal will do to us. We do not want any more needless deaths due to lack of healthcare.    Sincerely,  J Garland  Harrogate, TN 37752  mr.ulamog@icloud.com  8 Jonathan Reeve From: Sent: To: Subject: sgraymond@everyactioncustom.com on behalf of Sherrie Raymond Saturday, October 12, 2019 12:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.  Not only that, it's blatantly illegal ‐ no state can change how the federal Medicaid  program operates.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. It already does a poor job of ensuring access to health care for all those  qualified for Medicaid coverage.  The state should not be allowed to make changes to the Medicaid program without  federal oversight or eliminate federal standards, which are in place for the protection of patients. Without such  guardrails, the state could return to the days when managed care contractors failed to provide care to patients and  providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital health coverage  for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sherrie Raymond  332 Forestal Dr  Knoxville, TN 37918‐1979 sgraymond@outlook.com  9 Jonathan Reeve From: Sent: To: Subject: hugomouramarreiros@everyactioncustom.com on behalf of Hugo Conde Saturday, October 12, 2019 1:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Hugo Conde  1338 Cardinal Ave  Nashville, TN 37216‐2328 hugomouramarreiros@gmail.com  10 Jonathan Reeve From: Sent: To: Subject: dinkumthinkum@everyactioncustom.com on behalf of John Massey Saturday, October 12, 2019 3:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. John Massey  4062 Lone Wolf Cir  Crossville, TN 38572‐6565 dinkumthinkum@mac.com  11 Jonathan Reeve From: Sent: To: Subject: leesdunc@everyactioncustom.com on behalf of Lee Duncan Saturday, October 12, 2019 7:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Our Medicaid citizens who suffer from severe illness, must have the care need to manage their disease.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Tenncare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lee Duncan  3200 Club Tower Dr  Memphis, TN 38111‐3217 leesdunc@me.com  12 Jonathan Reeve From: Sent: To: Subject: dbouska@everyactioncustom.com on behalf of Diane Bouska Saturday, October 12, 2019 7:52 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Diane Bouska  224 Bermuda Dr  Nashville, TN 37214‐2034 dbouska@bellsouth.net  13 Jonathan Reeve From: Sent: To: Subject: diane.keeney@everyactioncustom.com on behalf of Diane Keeney Saturday, October 12, 2019 9:28 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Diane Keeney  1603 Stokes Ln  Nashville, TN 37215‐1511 diane.keeney@gmail.com  14 Jonathan Reeve From: Sent: To: Subject: jjanderson2@everyactioncustom.com on behalf of Jeffrey Anderson Saturday, October 12, 2019 9:55 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jeffrey Anderson  105 Jackson Ln  Jonesborough, TN 37659‐1511 jjanderson2@embarqmail.com  15 Jonathan Reeve From: Sent: To: Subject: clararoach59@everyactioncustom.com on behalf of Clara Roach Saturday, October 12, 2019 10:37 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I am against these cuts to the health care of people who would die without it, it's wrong and should be stopped immediately.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Clara Roach  3993 Bruce St  Morristown, TN 37814‐1128 clararoach59@gmail.com  16 Jonathan Reeve From: Sent: To: Subject: chistineconley8@everyactioncustom.com on behalf of Christine Conley Saturday, October 12, 2019 11:10 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Christine Conley  989 Philadelphia St  Memphis, TN 38104‐5825 chistineconley8@gmail.com  17 Jonathan Reeve From: Sent: To: Subject: caughttbpgr@everyactioncustom.com on behalf of Samantha Johnson Saturday, October 12, 2019 11:28 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Samantha Johnson  623 Minerva Dr  Murfreesboro, TN 37130‐6045 caughttbpgr@gmail.com  18 Jonathan Reeve From: Sent: To: Subject: poolperson916@everyactioncustom.com on behalf of Robin Burris Saturday, October 12, 2019 5:58 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Robin Burris  Kingston, TN 37763  poolperson916@aol.com  19 Jonathan Reeve From: Sent: To: Subject: schlacter9@everyactioncustom.com on behalf of Michael Schlacter Friday, October 11, 2019 9:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] This proposal removes money from the poor children and elderly persons on TennCare and transfers it into State Funding programs and does nothing to keep the failing rural hospitals intact   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Michael Schlacter  6037 Brentwood Chase Dr  Brentwood, TN 37027‐4449 schlacter9@gmail.com  20 Jonathan Reeve From: Sent: To: Subject: jr.henderson@everyactioncustom.com on behalf of Joshua Henderson Friday, October 11, 2019 10:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Joshua Henderson  105 Drew Ln  Bell Buckle, TN 37020‐4566  jr.henderson@gmail.com  21 Jonathan Reeve From: Sent: To: Subject: jw229@everyactioncustom.com on behalf of Jason Waldo Friday, October 11, 2019 8:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.       My wife and I are members of that category dependent on Medicaid. My wife is physically disabled, has Alzheimer's,  COPD, congestive heart failure, and other major health issues. She is a social security recipient due to her disabilities. I  stay home and care for her, her illness & disability creates an enormous hardship on me, as it has forced me into early  retirement to spend as many of her last days with her as possible. As a result our entire income for a family of 2 is  slightly under $1000 per month. While she is a TennCare recipient, I am not currently qualified and have no health care  whatever, this despite our impoverished level of finances.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     TennCare has it's flaws and problems, it currently serves the needs of one of us, if not the other. This attempt to gut  TennCare cannot be allowed, it will result in massive cut backs, loss of the little accountability that already exists, and, I  fear the loss of current coverage for my wife.     I also believe, beyond an attempt to punish the poor for their poverty, this proposal is an attempt to further intrude into  the private lives of half of our population to further move toward a theocracy in this country. To wit: interfering with  women's health and reproductive care with the express intent of imposing the religious will of one group upon  everyone. When one group tries this outside our country, we call it Islamic terrorism, I say that here it is Christian  terrorism. This is an attempt to further cut funding for Planned Parenthood. As a leading provider of reproductive health  care that sees Medicaid patients every day, Planned Parenthood understands that reproductive health is at particular  risk if Medicaid is block granted. Attempts to paint these proposals as anything but harmful or dangerous are misleading  and ignore the reality that women ‐‐ and women of color in particular ‐‐ would face even greater inequity in health care  access and poorer health outcomes.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  22   Sincerely,  Mr. Jason Waldo  590 Anderson Rd  Sweetwater, TN 37874‐6608 jw229@protonmail.com  23 Jonathan Reeve From: Sent: To: Subject: william.haynes@everyactioncustom.com on behalf of William Haynes Friday, October 11, 2019 9:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. William Haynes  1124 Timbergrove Dr  Knoxville, TN 37919‐8445 william.haynes@usa.net  24 Jonathan Reeve From: Sent: To: Subject: mara.bissell@everyactioncustom.com on behalf of Amarantha Martin Friday, October 11, 2019 10:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amarantha Martin  Nashville, TN 37211  mara.bissell@gmail.com  25 Jonathan Reeve From: Sent: To: Subject: ronaldwelch5100@everyactioncustom.com on behalf of Ron Welch Friday, October 11, 2019 11:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal   Dear Gabe Roberts,    Why change what has worked for so long?  Medicaid has worked for many people, and I am opposed to the proposal to  radically change Tennessee’s Medicaid partnership with the federal government by converting federal funding for  TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable  Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ron Welch  2400 Charlotte Ave  Nashville, TN 37203‐1667 ronaldwelch5100@att.net  26 Jonathan Reeve From: Sent: To: Subject: ccerutti1@everyactioncustom.com on behalf of Chloe Cerutti Friday, October 11, 2019 4:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Chloe Cerutti  2841 Vicwood Dr  Murfreesboro, TN 37128‐5846 ccerutti1@comcast.net  27 Jonathan Reeve From: Sent: To: Subject: skylar.bee@everyactioncustom.com on behalf of Skylar Bee Friday, October 11, 2019 4:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     These cuts would undermine those least able to afford health care ‐ especially those who already face barriers to care,  like people with low incomes, communities of color, individuals with disabilities, and people in rural areas.    As a leading provider of reproductive health care that sees Medicaid patients every day, Planned Parenthood  understands that reproductive health is at particular risk if Medicaid is block granted. Attempts to paint these proposals  as anything but harmful or dangerous are misleading and ignore the reality that women ‐‐ and women of color in  particular ‐‐ would face even greater inequity in health care access and poorer health outcomes.    The Medicaid program is a critical resource for preventative health services that millions of women rely on including  family planning services and pregnancy‐related care.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Skylar Bee  1626 16th Ave S Apt B1 Nashville, TN 37212‐2925 skylar.bee@gmail.com  28 Jonathan Reeve From: Sent: To: Subject: rose.dubois22@everyactioncustom.com on behalf of Rose DuBois Friday, October 11, 2019 4:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. These cuts would undermine those least able to afford health care ‐ especially  those who already face barriers to care, like people with low incomes, communities of color, individuals with disabilities,  and people in rural areas.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Reproductive health is at particular risk if Medicaid is block granted. Attempts to paint these proposals as anything but  harmful or dangerous are misleading and ignore the reality that women ‐‐ and women of color in particular ‐‐ would face  even greater inequity in health care access and poorer health outcomes. The Medicaid program is a critical resource for  preventative health services that millions of women rely on including family planning services and pregnancy‐related  care.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Rose DuBois  100 S 16th St  Nashville, TN 37206‐1907  rose.dubois22@gmail.com  29 Jonathan Reeve From: Sent: To: Subject: williams.wm.sk@everyactioncustom.com on behalf of William Williams Friday, October 11, 2019 4:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs **more accountability, not less**.     The state should not be allowed to make changes to the Medicaid program without federal oversight or eliminate  federal standards, which are in place for the protection of patients. Without such guardrails, the state could return to  the days when managed care contractors failed to provide care to patients and providers were left unpaid. This proposal  invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    These cuts would undermine those least able to afford health care ‐ especially those who already face barriers to care,  like people with low incomes, communities of color, individuals with disabilities, and people in rural areas.    As a leading provider of reproductive health care that sees Medicaid patients every day, Planned Parenthood  understands that reproductive health is at particular risk if Medicaid is block granted. Attempts to paint these proposals  as anything but harmful or dangerous are misleading and ignore the reality that women ‐‐ and women of color in  particular ‐‐ would face even greater inequity in health care access and poorer health outcomes.    The Medicaid program is a critical resource for preventative health services that millions of women rely on including  family planning services and pregnancy‐related care.        Sincerely,  William Williams  502 Strother Pl  Clinton, TN 37716‐3030  williams.wm.sk@gmail.com  30 Jonathan Reeve From: Sent: To: Subject: dondebsmith@everyactioncustom.com on behalf of don and deb smith Friday, October 11, 2019 5:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  don and deb smith  422 Dill Ln  Murfreesboro, TN 37130‐5807 dondebsmith@outlook.com  31 Jonathan Reeve From: Sent: To: Subject: trose315@everyactioncustom.com on behalf of Teresa Rhodes Friday, October 11, 2019 5:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Teresa Rhodes  1848 Fox Chase Dr  Goodlettsville, TN 37072‐4221 trose315@comcast.net  32 Jonathan Reeve From: Sent: To: Subject: laura.fortgang@everyactioncustom.com on behalf of Laura Fortgang Friday, October 11, 2019 5:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Laura Fortgang  Memphis, TN 38112  laura.fortgang@gmail.com  33 Jonathan Reeve From: Sent: To: Subject: httn2005@everyactioncustom.com on behalf of Brenda Hutton Friday, October 11, 2019 5:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  My son is 8 years old and has many complex medical conditions. He is on several medications for seizures which are  better controlled today that they have ever been but still has them daily. What would families like mine do if this block  Grant denied some of the meds that he separately needs??? My son didnt ask to be born with the these issues and I did  everything I was suppose to do when I was pregnant and yet all you are worried is the almighty dollar sign!!! What about  your most vulnerable people in this state if we as their parents don't fight for them no one else will. We already have to  fight for therapies and equipment and you want to add even more on top of it. Shame on you    Sincerely,  Brenda Hutton  360 Woodlawn Rd  Pulaski, TN 38478‐8145  httn2005@aol.com  34 Jonathan Reeve From: Sent: To: Subject: dovetwo@everyactioncustom.com on behalf of Cynthia Davis Friday, October 11, 2019 5:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Cynthia Davis  452 Bayhill Dr  Piney Flats, TN 37686‐4566 dovetwo@charter.net  35 Jonathan Reeve From: Sent: To: Subject: cfree1005@everyactioncustom.com on behalf of Cherie Free Friday, October 11, 2019 5:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Cherie Free  1005 Morrow Rd  Knoxville, TN 37923‐1768 cfree1005@comcast.net  36 Jonathan Reeve From: Sent: To: Subject: buckbuckminister@everyactioncustom.com on behalf of David George Friday, October 11, 2019 6:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  David George  1151 Tanglewood St  Memphis, TN 38114‐6719 buckbuckminister@gmail.com  37 Jonathan Reeve From: Sent: To: Subject: bobbytheburner@everyactioncustom.com on behalf of Robert Fingerman Friday, October 11, 2019 6:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Robert Fingerman  PO Box 977  Monteagle, TN 37356‐0977  bobbytheburner@charter.net  38 Jonathan Reeve From: Sent: To: Subject: fkeerobinson@everyactioncustom.com on behalf of F.K.Robinson Friday, October 11, 2019 6:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] This is just another reprehensible, malevolently sociopathic Republican attempt to rip healthcare away from as many human beings as possible! And the infamy: those cruel malefactors RECEIVE TAXPAYER-SUBSIDIZED CARE of the HIGHEST QUALITY...!!!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. F. K. Robinson  428 Brown Mountain Loop Rd  Knoxville, TN 37920‐6406 fkeerobinson@comcast.net  39 Jonathan Reeve From: Sent: To: Subject: fkeerobinson@everyactioncustom.com on behalf of F.K.Robinson Friday, October 11, 2019 6:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] THIS CRUEL, MALEVOLENT SOCIOPATHY IS AN OUTRAGE TO HUMANITY...!!!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. F. K. Robinson  428 Brown Mountain Loop Rd  Knoxville, TN 37920‐6406 fkeerobinson@comcast.net  40 Jonathan Reeve From: Sent: To: Subject: mflynnurness@everyactioncustom.com on behalf of Monica Flynn Urness Friday, October 11, 2019 7:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Monica Flynn Urness  4207 Sneed Rd  Nashville, TN 37215‐3213  mflynnurness@comcast.net  41 Jonathan Reeve From: Sent: To: Subject: elsachs@everyactioncustom.com on behalf of Edward Sachs Friday, October 11, 2019 7:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Edward Sachs  Nashville, TN 37205  elsachs@comcast.net  42 Jonathan Reeve From: Sent: To: Subject: sheralyn.lerner@everyactioncustom.com on behalf of Sheralyn Lerner Friday, October 11, 2019 7:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sheralyn Lerner  1710 Magnolia Blvd Apt 217 Nashville, TN 37212‐3736 sheralyn.lerner@comcast.net  43 Jonathan Reeve From: Sent: To: Subject: teaheadjones@everyactioncustom.com on behalf of CECI SACHS Friday, October 11, 2019 7:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. CECI SACHS  3600 Saratoga Dr  Nashville, TN 37205‐2540 teaheadjones@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: cbsspike@everyactioncustom.com on behalf of Carol Morgan Friday, October 11, 2019 7:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Carol Morgan  3314 Knox Ln  Knoxville, TN 37917‐1750  cbsspike@gmail.com  45 Jonathan Reeve From: Sent: To: Subject: tim10bob@everyactioncustom.com on behalf of Tim Armstrong Friday, October 11, 2019 7:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Tim Armstrong  11352 Highway 13 S  Linden, TN 37096‐4224 tim10bob@tds.net  46 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of jakirby@lipscomb.edu Sunday, October 13, 2019 11:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    As a pharmacist and educator, I am either involved in direct patient care or preparing the pharmacist workforce for the  realities they will encounter when they enter practice. Specifically, I practice part‐time in a setting that serves the  working uninsured in Tennessee (The Salvus Center‐Gallatin), but my colleague and I are only able to see patients in the  two days per week due to serious lack of resources in the clinic. Medicaid expansion as designated by the Affordable  Care Act is the most reasonable response to this health care access crisis in Tennessee. It would provide stability for my  patients and stability for the models I can tell my students to expect to see after they graduate. The Block Grants simply  do not account population growth and also do not well define the benefits TennCare members will actually see. I do  hope you this administration will reconsider this proposal and turn to Medicaid Expansion as an alternative.    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Justin  Kirby  1078 General George Patton Road  Nashville, TN 37221‐2597   47 Jonathan Reeve From: Sent: To: Subject: Billy Beaver Sunday, October 13, 2019 4:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Medicaid Propsal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I join many Tennesseans in expressing my grave concerns regarding the State of TN’s decision to convert its current  Medicaid program to a block grant program. Providing needed benefits through a block grant experiment threatens the  ability of beneficiaries to get the health care they need, and likely will irreparably harm the very people the Medicaid  program has been designed to help.     The proposed exemption from Federal requirements also negates important Federal oversight. In a misguided attempt  to save money, your proposal will hurt the most vulnerable among us and will have unintended consequences in how  effectively health care can be provided in TN.    Roberta Pearl  TN Voter    Sent from my iPad  48 Jonathan Reeve From: Sent: To: Subject: Rhonda Melton Sunday, October 13, 2019 4:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on Amendment 42     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I am extremely disappointed that the Block Grant funding for TennCare has passed in the state of Tennessee, but since it  has, I hope you will take my concerns into account.    In the executive summary of Amendment 42 draft it is called an "innovative proposal".  I disagree with this  characterization.    1. The block grant does not cover 300,000 Tennesseans currently uninsured or under insured.    2. The block grant allows limitations on medication choices. TennCare currently covers the most vulnerable citizens in  Tennessee. Any change to covered medications will endanger lives!    3. There are no safeguards in place to protect the program from budget cuts if funding is needed in other areas of the  state budget.    4. The Block Grant proposal is requesting the release of the TennCare program from federal oversight and  accountability. This is unacceptable.   If a program receives funding from the federal government, it is only reasonable and prudent to expect oversight and  accountability.    I don't see any "innovation" in the above issues, just a disregard for human life.    Thank you for considering my comments on this issue.    Rhonda Melton      49 Jonathan Reeve From: Sent: To: Subject: DIANA PAGE Sunday, October 13, 2019 2:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] No to Medicaid Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   1. The Block Grant does not cover the 300,000 persons currently uninsured or underinsured.  2. The Block Grant gives the state the ability to limit medication choices.  Standardized formularies will not work  for patients who require specific medications for specific conditions.  TennCare currently covers the most  vulnerable and disabled Tennesseans.  Any changes to the current formulary will endanger this population.   3. The Block Grant does not keep the state from cutting services if additional monetary resources are needed for  the state budget.  4. The Block Grant proposal is requesting to be released from federal oversight and accountability with regard to  the TennCare program.  In my opinion, without federal oversight, the clients will come up far short.  Further,  reproductive health is likely to be even further diminished.  I would be shocked if adequate funding for  substance use and mental health was provided.  Besides the above issues, I am very concerned that the State of TN can responsibly administer a Block Grant. Besides the unspecified administrative costs, history has shown that unfortunately the State of TN does not have a good track record in administering, for instance, health care for underinsured children. Further, health care in State prisons, surely the responsibility of the State, had been ineffective. In my opinion, the State of TN, in the end should also take responsibility for the poor health care of those in jail. Why does the State think that it can implement such large changes to insuring the underprivleged successfully. I would like to suggest that you successfully administer the children's healthcare program, make strides in substance abuse treatment, and overall poor TN health measures, before taking on a Block Grant. Sincerely, Diana Page 50 Jonathan Reeve From: Sent: To: Subject: Nelson Sharp Sunday, October 13, 2019 2:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Proposed block grant for Tennessee     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  To whom it concerns,  My name is Nelson Sharp I’m a 64 year  old resident of Tennessee and have been all my life. At this time I work full time  but plan to retire soon. I have health care coverage through my employer now but after retirement that will change.   I also have a five year old granddaughter with with a disability she was born with. She requires special care because she  cannot feed herself, requires someone to stay with her 24 hours a day,  cannot talk, requires to be tube fed, and  depends on the much needed physical and occupational therapy that has helped her to walk, use sign language, and so  many more functions that she would have never been able to achieve on her own. This has been a very costly and tiring   process for all her family. Both parents work so their income requires them to rely on private insurance which limits the  amount of care she gets.   When the Katie Beckett process was passed for Tennessee we could see possibly some assistance for her to get the care  she needs, but now our law makers are considering a block grant for Tennessee. We were the last state to pass Katie  Beckett and I think one of the first states to use a block grant so my concern is will this work or will it be an out for  Tennessee not to pay for the care of people who depend on the state for health care coverage? After I retire should I  become disabled and require nursing care will it help me? Will it help my granddaughter who needs care each day  because she cannot do it herself?   Myself and my granddaughter are not the only people who do need or possibly could need help with health care. Is  Tennessee considering them or a budget that leaves them behind?   I have supported the state and government all through my working years and have contributed my share to pay for the  state to help with health care for our elderly, disabled, and special need patients.   Now my concern is will I have it? Will my granddaughter finally get help she deserves without all her family trying to self  pay to keep her alive? Will a block grant leave Tennessee on their own after a couple of years of rising health care cost?  What is so good about a block grant and limiting have much federal assistance we get?  I voted these law makers in office, I support‐pay and still support‐pay for all a system that leaves no one behind. This is  our responsibility and our God has made his commandments known throughout the Bible teaching us that.   Where does Tennessee and our law makers stand? My prayer for them is with God.  Nelson Sharp  CELL: 423‐817‐1613  51 Jonathan Reeve From: Sent: To: Subject: James Melton Sunday, October 13, 2019 1:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose Block Grant Funding for TennCare     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I would like to register my opposition to Governor Lee's plan to apply Block Grants to TennCare and its recipients.    As of now, approximately 300,000 Tennesseans are already uninsured or underinsured. Block Grants will not cover these  people and will make things worse for the folks who are currently covered by TennCare.    If Governor Lee's plan is implemented, there is no assurance that services will not be cut if it is decided that the state  needs more money from "somewhere". So the decision will be, "Oh well, we'll just cut TennCare support (again) for our  citizens that need it the most".    The Governor has decided that he doesn't want the TennCare program to be accountable to anyone, including oversight  which is absolutely essential from the Federal level. This is just plain wrong and an attempt to hide the disaster that  Block Grant funding will surely become if put into effect.    The fact that Tennessee refused to expand Medicaid when the resources to do so were offered to the state is  reprehensible and an enormous mistake.  Please don't make another mistake by placing another health care and  economic burden on the backs of Tennessee's poor and disadvantaged.    Sincerely,    James Melton  1544 Cavalier Drive  Maryville, TN 37803    52 Jonathan Reeve From: Sent: To: Subject: kay.norman@everyactioncustom.com on behalf of Kay Norman Sunday, October 13, 2019 9:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans. It is also likely that reproductive health and other preventative health services are at  particular risk under this proposal.     The medical community is strongly opposed to the block proposal, giving lie to the governor's assertion that the people  who are opposed simply don't understand it. I believe that the dangers in this proposal are transparently obvious and I  join with the many other Tennesseans who are strongly against it.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Kay Norman  5958 Manchester Pike  Murfreesboro, TN 37127‐7811 kay.norman@comcast.net  53 Jonathan Reeve From: Sent: To: Subject: Tracie Walker, MD Sunday, October 13, 2019 8:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I disagree with this amendment as it is designed to decrease health benefits to the poor for the purpose of saving the  state money.  It is an inhumane proposal that places money over human life and well being.    Tracie A. Walker, M.D.    Sent from my iPhone  54 Jonathan Reeve From: Sent: To: Subject: ontogenyx@everyactioncustom.com on behalf of James Horn Sunday, October 13, 2019 8:08 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  James Horn  6424 Bresslyn Ct  Nashville, TN 37205‐3023 ontogenyx@gmail.com  55 Jonathan Reeve From: Sent: To: Subject: Jennifer Westerholm Sunday, October 13, 2019 7:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] opposed to TennCare block grant (amendment 42)   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   1. The Block Grant does not cover the 300,000 persons currently uninsured or underinsured. 2. The Block Grant gives the state the ability to limit medication choices. Standardized formularies will not work for patients who require specific medications for specific conditions. TennCare currently covers the most vulnerable and disabled Tennesseans. Any changes to the current formulary will endanger this population. 3. The Block Grant does not keep the state from cutting services if additional monetary resources are needed for the state budget. 4. The Block Grant proposal is requesting to be released from federal oversight and accountability with regard to the TennCare program. Thank you,  Jennifer Westerholm  37206    56 Jonathan Reeve From: Sent: To: Subject: Alfred Denny Sunday, October 13, 2019 7:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TenCare Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am opposed to the Block Grant funding for TennCare. IT does not cover the 300,000 persons currently uninsured or  underinsured. IT gives the state the ability to limit medication choices. TennCare currently covers the most vulnerable  and disabled Tennesseans.  Any changes will endanger this population. IT does not keep the state from cutting services if  additional monetary resources are needed. IT requests to be released from federal oversight and accountability.   Alfred Denny; 238 N Tulane Ave; Oak Ridge. TN 37830‐6308  57 Jonathan Reeve From: Sent: To: Subject: Linda Pearce Saturday, October 12, 2019 8:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grants     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I think the Block Grants are a bad idea.  Medicaid /Tenncare will help more people.  Linda L Pearce  58 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of gsieber@att.net Saturday, October 12, 2019 8:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    Tennessee Health Care Campaign has several concerns about this proposal. Primarily, we care concerned:  I know people who could be severely affected if Amendment 42 goes into effect.         This waiver does not ask for funds sufficient to cover working Tennesseans in jobs that do not provide health  insurance. These approximately 300,000 Tennesseans earn to much to enroll in TennCare and not enough to enroll in  ACA marketplace plans.             The state is also proposing to "use block grant funds on public health initiatives that are not specifically targeted at the  TennCare population." This could create a scenario in which TennCare beneficiaries receive limited benefits, while other  populations (such as higher‐income Tennesseans who earn too much to qualify for TennCare) benefit from the state's  flexible use of federal funds.             Allowing Tennessee the unchecked power to limit benefits or target certain populations has the potential to deepen  health inequities among people who are in poverty, who are non‐Caucasian, and/or people who experience other  discrimination in health care.    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.        Sincerely,  Mildred Beard Sieber    Respectfully,  59   Mildred Sieber  210 ST CLAIR LN  MARYVILLE, TN 37804‐3577   60 Jonathan Reeve From: Sent: To: Subject: Betsy McMullen Saturday, October 12, 2019 3:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please stop the Block Grant and all the damage it will do to our neediest citizens.   Elizabeth McMullen 37075  ‐‐   Betsy  61 Jonathan Reeve From: Sent: To: Subject: Ariel Christen Saturday, October 12, 2019 1:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Dear TennCare officials   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, TennCare is important to me, Ariel Inman, as well as my mother Mary Wicks who is schizophrenic. It provides comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare has helped my mother and young cousin by providing institutions for them when they're in serious need of help. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely, Ariel Inman 62 Jonathan Reeve From: Sent: To: Subject: Joan Sands Saturday, October 12, 2019 12:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] PLEASE DO NOT PROCEED-- I HAVE SOBERING CONCERNS ABOUT AMENDMENT 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   TO WHOM IT MAY CONCERN,     I am a SOCIAL WORKER who has serious concerns about AMENDMENT 42.    I am in contact with people that are uninsured and / or underinsured daily.   AMENDMENT 42  will HAVE A HUGE IMPACT ON THEM.   I am devastated to learn that Governor Lee's recent bill that past during the legislative session requesting BLOCK GRAND  FUNDING FOR TENN CARE will impact  300,000 people who will not be covered.   AREN’T those the most vulnerable in need ?   What are the PRIORITIES HERE??  WHO IS HE BEST SERVING?    PLEASE PLEASE CONSIDER THE IMBALANCE OF THIS AMENDMENT!!!!    It also gives the State the power to limit medication choices.   This level of power frightens me as this becomes a subjective interpretation of need/ Standardized formularls will NOT work  for all patients.     AGAIN TennCARE currently covers the most vulnerable and disabled in TN.   WHY ARE WE SETTING UP BARRIERS AND LIMITATIONS??  I feel this will create exhausting health problems for those who need the medication and those of us trying to help those in  need— Health care/Hospitalization will increase etc.    My understanding is the BLOCK GRANT does not prevent the state from cutting services if additional monetary resources are  needed for the state budget  THIS IS ALSO FRIGHTENING TO ME… HOW ARE WE PROTECTING THOSE IN NEED IF THE MONEY CAN BE REDIRECTED SO  EASILY FROM OUR VULNERABLE  NEEDY POPULATION WHO CANNOT ADVOCATE ( BE HONEST) For THEMSELVES WHEN IT IS  BEING DISCUSSED‐‐‐    In addition the proposal is requesting to be released from federal oversight and accountability with regard to TennCARE  program ‐ WHY??????  What do they have to fear?  Why can’t they be accountable.   This really frightens me—— PLEASE PLEASE DO NOT ALLOW THIS.         PLEASE RE‐THINK THIS AMENDMENT — IT DOES NOT SERVE THOSE IN NEED THE MOST — IT ALLOWS LEGISLATURE TOO  MUCH POWER TO CHANGE/ REARRANGE OR TAKE AWAY what TennCare provides with NO ACCOUNTABILITY= that is NOT  FAIR TO THOSE IT SERVES— TOO MUCH POWER to those in power!!  63   A SOCIAL WORKER… getting weary … as I try and serve those in need and services just keep getting CUT.     Joan Sands, MSW  3119 Forrest Park Ave  Nashville TN  37215                64 Jonathan Reeve From: Sent: To: Subject: leslie badaines Saturday, October 12, 2019 11:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Funding for Tenncare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the use of block grants to replace TennCare for the following reasons:  1. This proposal removes Federal oversight and Accountability.  2. Healthcare is a right that should be available to all citizens who need it! The Block grant does not cover over 300,000  Tennesseans who are uninsured.  3. If the State uses all funds due to over expenditure, services to those needing healthcare will be cut.   4. The block grant gives the State the right to limit medication choices. Sometimes standard formularies do NOT work for  patients and they need other medications. This proposal should include a procedure for health care providers to request  other medications.     By opposing Medicaid expansion, Tennessee has done a great disservice to its vulnerable populations, which,  unfortunately, are many in this State. Hospitals in rural areas have closed, and access to health care has been grossly  limited. This Block grant proposal only exacerbates an already terrible health care crisis in our State.    Government should be By and For the People, and instead of attempting to suppress services.    Leslie Badaines  438 Circle Hill Drive  Knoxville, TN    Sent from my iPad  65 Jonathan Reeve From: Sent: To: Cc: Subject: LINDA MYRTLE Saturday, October 12, 2019 10:50 AM PUBLICE NOTICE TENNCARE lmyrtintn@icloud.com [EXTERNAL] Tenncare     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐    Dear TennCare officials,    TennCare is important to me and my family.  It provides comprehensive health care coverage for people in need.  TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential  health treatments and manage their condition.  TennCare has helped my family by providing much needed services and  medications to keep him out of the hospital.    I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal  would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this  proposal would allow the state to eliminate or restrict services that are important to people with mental illness.     More people need access to TennCare, not less.     I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not  hurt them.     Sincerely,  Linda Myrtle   Sent from my iPhone  66 Jonathan Reeve From: Sent: To: 9312012101@mms.att.net Saturday, October 12, 2019 10:07 AM PUBLICE NOTICE TENNCARE Previous email correction of typo from "black" to "block":  I am greatly opposed to the draft waiver proposal, to ANY  proposal to convert TennCare into a "block grant" ! Lucy Meriwether, Lawrenceburg, TN  67 Jonathan Reeve From: Sent: To: Subject: jjanderson2@everyactioncustom.com on behalf of Janet Anderson Saturday, October 12, 2019 9:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Janet Anderson  105 Jackson Ln  Jonesborough, TN 37659‐1511 jjanderson2@embarqmail.com  68 Jonathan Reeve From: Sent: To: Subject: Judy Shank Saturday, October 12, 2019 7:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Oppose Block Grant funding for TennCare   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am writing to state my opposition to Gov. Lee's Block Grant funding for TennCare. I offer the following reasons for my opposition: 1. The Block Grant does not cover the 300,000 persons currently uninsured or underinsured. 2. The Block Grant gives the state the ability to limit medication choices. Standardized formularies will not work for patients who require specific medications for specific conditions. TennCare currently covers the most vulnerable and disabled Tennesseans. Any changes to the current formulary will endanger this population. 3. The Block Grant does not keep the state from cutting services if additional monetary resources are needed for the state budget. 4. The Block Grant proposal is requesting to be released from federal oversight and accountability with regard to the TennCare program.   Judy Shank  6908 Collinswood Drive  Nashville TN 37221-3959  69 Jonathan Reeve From: Sent: To: Subject: Mary Ball Saturday, October 12, 2019 5:22 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the proposal because it does not ensure funds are going to be used solely to meet health care needs of  Tennesseans.  70 Jonathan Reeve From: Sent: To: Subject: Anne Child Friday, October 11, 2019 9:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerned about block grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   1. One of the provisions of the Affordable Care Act was the ability of states to expand medicaid to cover more people,  those not currently covered or under‐insured.  This proposal does not cover those people.    2.  Standardized formularies are problematic.  My husband encountered this with our past insurance.  He had Multiple  Sclerosis.  The drug he was using started causing kidney damage.  The alternative he and his neurologist preferred was  not available on his plan.  He ended up on an older drug that appeared not to be effective.  So he tried to get approval  for yet another drug.  It was an incredibly stressful frustration for him.  It would seem to me that a countrywide system  would allow for better pricing on drugs than different formularies for different states.      Anne Child  512‐919‐9271  35 Riverside Dr.  Oak Ridge, TN 37830  71 Jonathan Reeve From: Sent: To: Subject: JOSEFINA PALMER Friday, October 11, 2019 7:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenn Care and The Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, TennCare is important to my daughter and I]. It provides comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare has allowed my special needs daughter, to have health care and services received, that I would not be able to afford. I am a retiree, on a very limited income. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness. Sincerely, Josefina Palmer 72 Jonathan Reeve From: Sent: To: Subject: Cathie Buckner Friday, October 11, 2019 6:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant scares me to death   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Separation of the State and it’s poor.  Creation of Block Grant  This is what the State is good at:  Throwing 185,000 children off TennCare rolls the year they  want to show the Feds significant savings that this State has  made.  Some mistake?  No on purpose….100,000 of that  purge is still without coverage.    What this State is also good at:  Not increasing or even  opening any enrollment periods for  eligible  TennCare/Medicaid for our children, the disabled,  or for seniors with only social security or those with no  social security at all.   The State proclaimed at the public meetings that this Block  Grant ‘good idea’ will not affect children, those already on  SSI, or the lowest income seniors currently getting the  service.  This is total horse feathers.  I say to that it already  had affected me.  They affect any and every one they can at  73 every chance they get.  This can look like a saving but it is  not.  It causes more emergency room visits and causes for  treatable conditions to balloon into much more expensive  need for care.    This is not our fault.  These children cut off cannot fill out  paperwork and some of their parents can’t either and  sometimes the forms never get there or are discarded amid  the array of junk health care mail we all seem to get.  The  junk mail that these families get for signing up for this plan  or that plan.  Who reads all that?  Not me.   Or do they even  get delivered or the fact that no one may even be home  during mail drop times because of the work or volunteer  requirements The State has put on their parent/s.  The State  has no proof they sent 185,000 letters out.   The fact is it will affect these folks.  The fact that your  hearing was led off by someone representing the State  saying it will not affect these folks.   This is simply further  reason for dis‐trust and dis‐belief.      I say this is not only misleading, it is not true.  I am a  witness.  I was purged from this role in 2013 and was not  allowed by the State to re‐enroll.  The Bureau of Medicare  made the State re‐enroll me when I turned 65.  Because I  74 qualify.  I always qualified.  But for the State I missed the  appeal time and that was that for the State.  I suffered over a year with a prolapsed uterus that got  worse and worse and worse.  It became unbearable but I  could not do anything but suffer because I did not have the  other 20%.  Heaven forbid that I still had Medicare because  I have worked enough to still have that benefit.  In those  years I only went to seek any medical help only twice in that  timeframe…Thank God for minute clinics (which are also  disappearing just like rural hospitals).      This State has more closed rural hospitals than any other  state per capita in the country and the talk is that an  additional savings proposed is to do away with air  ambulance services.    So what do these people do if the magic hour is not going to  be a possibility for them to reach emergency care?  I can tell  you they will die.  How will people with strokes, with heart  attacks, with aneurisms, those in car/bike/pedestrian  accidents, or gun‐shot wounds, or of simply falling, or  preemies or woman with problem pregnancies…what will  they do?    I can tell you, they will die, needlessly.  And The  State will not take on iota of blame.  Lee will ask us to pray  about it.  But he is the one who doesn’t understand.  For his  75 secret meetings with deep pocket folks who have ‘‘a stake’’  in getting the money not one person impacted by these so  called “good ideas” was there. The State scares me to death  because we are last in taking care of the unhoused, our  babies, our hungry children.  We have a doubly higher  infant mortality rate among families in poverty.  And in  region 2 it is double that.  It is terrible to be poor in  Tennessee.  And as I said before I am terrified as to what  this lack of oversite will cause.  The artificial donut hole that  private insurers created to boost their profits will in this  proposed program will be a gaping hole that will simply  write many of us off.  Of all those who spoke, the doctors,  lawyers, priests, parents advocates, even Jim Cooper and  me were all against this.  As it was in the other two  places.  The choices for a place to meet, the way it wasn’t  advertised, the time it was scheduled still for all the good  souls there no Lee, no fat cats with the deep pockets and no  folks who crafted this bill to listen to us.  And the obvious  lack of young mothers, the disabled, the elderly.  The State  did not want them there.   Governor Lee I had a question  but you were not there and no one was going to answer.  My question that you did not let me ask at the meeting is to  know who is the body, organization, or person who will  76 approve or disapprove this Block Grant ‘‘bad idea”?  Please  copy these comments and sent to him/her/them.  Thanks.  Cathie Buckner  615‐973‐1069          77 Jonathan Reeve From: Sent: To: Subject: Carole Kenner Friday, October 11, 2019 6:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***       To whom it may concern,      I am astonished that the Block Grant is not at this time planning to be used to cover the 300,000 persons currently uninsured or underinsured in Tennessee. I thought the purpose of the Block Grant was to help more low and moderate income people get more and better coverage, particularly those in rural and underserved areas where our citizens are desperately in need of better health care services. What is going on here??    Carole Kenner  1901 Cedar Lane  Nashville,TN 37235  78 Jonathan Reeve From: Sent: To: Subject: Brian Paddock Friday, October 11, 2019 5:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Please do not ask for a blank check “Block Grant” from Federal Medicaid for TennCare.   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   My comment on Governor Lee’s request for a blank check “Block Grant” from Federal Medicaid  for TennCare.       TennCare is especially important in our rural areas like our upper Cumberland counties – 30% of Tennesseans live in  rural areas.    Currently TennCare provides health care to 1.4 million Tennessee adults and children. Half of our children  have TennCare as their only access to doctors and hospitals.  Sixty percent of our family and friends in nursing homes  rely on TennCare to pay for care.       Federal Medicaid funds are 1/5 of our state budget and about half of all the federal money that comes to  Tennessee.  That is a lot of jobs in healthcare.      Unfortunately the conservative majority in the Legislature has blocked all efforts to get more of our federal tax dollars  back by expanding TennCare to very low income working adults.  Thirty seven states, both blue and red, have expanded  their Medicaid programs.  Our legislative majority rejected Republican Governor Haslam’s efforts to make a deal with  the federal Medical program to expand TennCare.      The result has been closing rural hospitals – Tennessee has more rural hospital closings in proportion to our  population than any state in the nation.  Recently the TennCare Bureau dropped about 160,000 children from  TennCare.  Most of these terminations were due to bureaucratic error.       Rural hospitals close when folks lack insurance and can’t pay for care.  Tennessee is losing its rural healthcare, in large  part, because our Legislature did not bring back at least 7 Billion of our tax dollars sent to Washington as Medicaid  dollars for TennCare expansion.      Now Governor Lee and the TennCare Bureau have a “plan” asking for a blank check for TennCare with no rules  attached.      The federal Medicaid law has rules about who is eligible to receive TennCare coverage for medical expenses.  It has  rules about what healthcare services must be provided and paid for with Medicaid funds. These rules have mostly  worked well to assure that the truly very poor, truly sick or injured get medically necessary care.      Governor Lee claims he might “save” 1 Billion dollars each year if TennCare is a fixed amount as a Block Grant with no  federal rules including rules that control how health care is delivered through Managed Care Organizations.       The truth is that our state government will keep only half of any money “saved”, with the rest going to the federal  government. Worse yet the “savings” will come from taking $2 billion out of Tennessee’s healthcare system.  That is a  billion less to help patients and cuts income for our doctors, clinics, and hospitals to enrich the state and federal  governments.      The State plan says “Tennessee [already] operates one of the most cost‐effective Medicaid programs in the  nation.”  The only way to get any “savings” is to cut vitally necessary medical care to the state’s most vulnerable  patients. The plan is to reduce the amount of care a patient could receive. For example: TennCare might only cover one  drug in a class or it could go back to the policy of only covering 14 days a year of in‐patient hospital care.  People with  chronic illness and the greatest need will be targeted for cuts to produce “savings”.       Gov. Haslam’s “Insure Tennessee” plan would have brought in $1.4 billion each year of new federal dollars to cover  working families, rather than extracting $2 billion out of the system.  The Block Grant request is proof of our lawmakers’  failure to deal with (1) declining insurance coverage among children (2) our highest rate of rural hospital closures in the  U.S. (3) the drug overdose epidemic (4) increasing medical debt and bankruptcy and (5) threats to people with pre‐ existing conditions.      This comment was published as an open letter in the Cookeville newspaper.  79 -Brian Paddock, Esq. 360 Roberts Hollow Lane Cookeville TN 38501 931-268-2938 (voice & fax by prior arrangement) 80 Jonathan Reeve From: Sent: To: Subject: Linda Ballenger Friday, October 11, 2019 5:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant health care     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  To set up a program that has no over‐site by the federal government will bring great danger to the most vulnerable  citizens of Tennessee this an atrocity. We are judged not my how much money we make off of the poor but how well we  care for them.     Sent from my iPhone  81 Jonathan Reeve From: Sent: To: Subject: sgmarshathome@everyactioncustom.com on behalf of Suzanne Marsh Friday, October 11, 2019 1:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] https://www.medpagetoday.com/publichealthpolicy/ethics/82637?xid=nl_badpractice_ 2019-10-11 &eun=g748151d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=BadPractice_ 101119&utm_term=NL_Gen_Int_Bad_Practice%20-%20Active   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Suzanne Marsh  175 GLENWOOD Dr  Clarksville, TN 37040  sgmarshathome@gmail.com  82 Jonathan Reeve From: Sent: To: Subject: karen1679@everyactioncustom.com on behalf of Karen Adams Friday, October 11, 2019 2:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    This appears to be yet another roadblock to care for those who need it most. I urge you to oppose this change, and  thank you for your consideration in advance.    Sincerely,  Ms. Karen Adams  4415 Hartland Ln  Knoxville, TN 37938‐3157 karen1679@tds.net  83 Jonathan Reeve From: Sent: To: Subject: johnawilson@everyactioncustom.com on behalf of John Wilson Friday, October 11, 2019 2:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] As a healthcare business executive in Nashville, I strongly oppose the block grant proposal. Expanding medicaid instead will offer more for the state's economy and health than the block grant or our current TennCare system. Expand medicaid now.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  John Wilson  1701 6th Ave N  Nashville, TN 37208‐2203 johnawilson@gmail.com  84 Jonathan Reeve From: Sent: To: Subject: wjb618@everyactioncustom.com on behalf of William Brisolara Friday, October 11, 2019 2:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. William Brisolara  561 S Reese St  Memphis, TN 38111‐4335  wjb618@comcast.net  85 Jonathan Reeve From: Sent: To: Subject: ari.baker37@everyactioncustom.com on behalf of Ari Baker Friday, October 11, 2019 2:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ari Baker  2407 Webster Ct  Maryville, TN 37804‐2649 ari.baker37@gmail.com  86 Jonathan Reeve From: Sent: To: Subject: emailthisguy@everyactioncustom.com on behalf of Mike Kite Friday, October 11, 2019 2:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mike Kite  Chattanooga, TN 37415  emailthisguy@gmail.com  87 Jonathan Reeve From: Sent: To: Subject: marcellecole@everyactioncustom.com on behalf of Marcelle Cole Friday, October 11, 2019 2:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Marcelle Cole  605 Mccarley Ave  Madison, TN 37115‐4137 marcellecole@yahoo.com  88 Jonathan Reeve From: Sent: To: Subject: tjh79psu@everyactioncustom.com on behalf of Tim Hacker Friday, October 11, 2019 2:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    As an instructor at the University of Tennessee at Martin,  I have worked with many students who rely on Tenncare.  I  am fearful of what any changes to the program will mean for them.    Sincerely,  Mr Tim Hacker  101 Meadowview Dr  Fulton, KY 42041‐1834 tjh79psu@icloud.com  89 Jonathan Reeve From: Sent: To: Subject: scarlett.bacon@everyactioncustom.com on behalf of Scarlett Bacon Friday, October 11, 2019 2:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Scarlett Bacon  3618 Dorchester Dr  Rowlett, TX 75088‐6580 scarlett.bacon@gmail.com  90 Jonathan Reeve From: Sent: To: Subject: burkman.publicity@everyactioncustom.com on behalf of Jack Burkman Friday, October 11, 2019 2:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Jack Burkman  Washington, DC 20330  burkman.publicity@outlook.com  91 Jonathan Reeve From: Sent: To: Subject: susanhathcock@everyactioncustom.com on behalf of Susan Hathcock Friday, October 11, 2019 2:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Susan Hathcock  303 E 2nd Ave  Lenoir City, TN 37771‐2511 susanhathcock@gmail.com  92 Jonathan Reeve From: Sent: To: Subject: katrowellpa@everyactioncustom.com on behalf of Kathy Rowell Friday, October 11, 2019 2:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The Medicaid program is a critical resource for preventative health  services that millions of women rely on including family planning services and pregnancy‐related care.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.       Sincerely,  Kathy Rowell  1803 Mountain Bay Dr  Hixson, TN 37343‐6108 katrowellpa@yahoo.com  93 Jonathan Reeve From: Sent: To: Subject: karen.karpinski10@everyactioncustom.com on behalf of Kare Karpinski Friday, October 11, 2019 2:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Kare Karpinski  113 March Pl  Mount Juliet, TN 37122‐2573 karen.karpinski10@gmail.com  94 Jonathan Reeve From: Sent: To: Subject: tmh625@everyactioncustom.com on behalf of Teresa Halloran Friday, October 11, 2019 2:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     These cuts would undermine those least able to afford health care ‐ especially those who already face barriers to care,  like people with low incomes, communities of color, individuals with disabilities, and people in rural areas.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     As a leading provider of reproductive health care that sees Medicaid patients every day, Planned Parenthood  understands that reproductive health is at particular risk if Medicaid is block granted. Attempts to paint these proposals  as anything but harmful or dangerous are misleading and ignore the reality that women ‐‐ and women of color in  particular ‐‐ would face even greater inequity in health care access and poorer health outcomes.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     The Medicaid program is a critical resource for preventative health services that millions of women rely on including  family planning services and pregnancy‐related care.    This waiver is fundamentally flawed. It goes against the goals and purpose of the Medicaid program. I respectfully urge  you not to go forward with this harmful proposal.    Sincerely,  Mrs. Teresa Halloran  100 Blossom Ct  Franklin, TN 37064‐0741  tmh625@comcast.net  95 Jonathan Reeve From: Sent: To: Subject: cmorse@everyactioncustom.com on behalf of Carol Morse Friday, October 11, 2019 2:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     Sincerely,  Carol Morse  5916 Noyes Ct Apt 4 Memphis, TN 38119‐5175 cmorse@memphis.edu  96 Jonathan Reeve From: Sent: To: Subject: laurie.t.schell@everyactioncustom.com on behalf of Laurie Schell Friday, October 11, 2019 2:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     These cuts would undermine those least able to afford health care ‐ especially those who already face barriers to care,  like people with low incomes, communities of color, individuals with disabilities, and people in rural areas.    Sincerely,  Laurie Schell  503 Ashlawn Ct  Nashville, TN 37215‐6137 laurie.t.schell@gmail.com  97 Jonathan Reeve From: Sent: To: Subject: greerfox@everyactioncustom.com on behalf of Greer L.Fox Friday, October 11, 2019 2:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Do NOT convert TennCare to a block grant   Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” This proposal jeopardizes coverage for vulnerable Tennesseans and  does nothing to assist the less affluent among our state's people.     Tennessee's population is high on every list of health issues:  obesity, opioid addiction, low birth weight infants, fetal  alcohol and opioid addiction, tuberculosis, cancers, diabetes, heart and lung issues, suicide, and gun‐related accidents  and injuries.  The injury to rural women in particular that this proposal will cause cannot be overstated.    The Tennessee legislature has been and continues to be tone‐deaf when issues of public health arise.  Secure in their  own tax‐payer funded health insurance for life ("It's great to be a Tennessee pol!"), they continue to ignore the well‐ being of the underserved populations in our rural counties and urban neighborhoods (Memphis, Nashville, Knoxville,  Chattanooga).      This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.        Sincerely,  Dr. Greer L. Fox  413 Cutlass Rd  Knoxville, TN 37934‐4019 greerfox@charter.net  98 Jonathan Reeve From: Sent: To: Subject: npgriffith1@everyactioncustom.com on behalf of Nancy Griffith Friday, October 11, 2019 2:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     These cuts would undermine those least able to afford health care ‐ especially those who already face barriers to care,  like people with low incomes, communities of color, individuals with disabilities, and people in rural areas.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Nancy Griffith  515 Brentwood Cir  Clarksville, TN 37042‐3485 npgriffith1@gmail.com  99 Jonathan Reeve From: Sent: To: Subject: maryeagee@everyactioncustom.com on behalf of Mary Agee Friday, October 11, 2019 2:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     These cuts would undermine those least able to afford health care ‐ especially those who already face barriers to care,  like people with low incomes, communities of color, individuals with disabilities, and people in rural areas.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Mary Agee  6501 Currywood Dr  Nashville, TN 37205‐3027 maryeagee@gmail.com  100 Jonathan Reeve From: Sent: To: Subject: viablex1@everyactioncustom.com on behalf of Matt Friel Friday, October 11, 2019 2:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Matt Friel  1803 Mountain Bay Dr  Hixson, TN 37343‐6108 viablex1@gmail.com  101 Jonathan Reeve From: Sent: To: Subject: kcardin@everyactioncustom.com on behalf of Kacey Cardin Friday, October 11, 2019 2:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     As a woman who depended on Medicaid for a brief period in my own life, I can personally attest to how vital it is that  citizens, especially women, have access to full spectrum healthcare regardless of income bracket or life circumstances.  Without that care, my entire life could have been jeopardized because of a vulnerable few months; a government for  the people should not put its citizens at such risk.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully implore you not to go forward with this harmful proposal.    Sincerely,  Kacey Cardin  710 Cleo Miller Dr Apt 550 Nashville, TN 37206‐2589 kcardin@gmail.com  102 Jonathan Reeve From: Sent: To: Subject: 911phatchick@everyactioncustom.com on behalf of KELLY WALKER <911phatchick@everyactioncustom.com> Friday, October 11, 2019 3:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms KELLY WALKER  1527 A Richmond Rd  Columbia, TN 38401‐9083 911phatchick@gmail.com  103 Jonathan Reeve From: Sent: To: Subject: chika386@everyactioncustom.com on behalf of chika chimezie Friday, October 11, 2019 3:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  chika chimezie  Nashville, TN 37203  chika386@gmail.com  104 Jonathan Reeve From: Sent: To: Subject: luvclown@everyactioncustom.com on behalf of Tm.Prudhomme Friday, October 11, 2019 3:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose Medicaid Block Grant Proposal   Dear Gabe Roberts,    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans, particularly those who are less fortunate than others.        Sincerely,  Tm. Prudhomme  1365  Memphis, TN 38104  luvclown@gmail.com  105 Jonathan Reeve From: Sent: To: Subject: nrsbek@everyactioncustom.com on behalf of Rebecca Watkins Friday, October 11, 2019 3:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Rebecca Watkins  440 Defoe Cir  Maryville, TN 37804‐2702  nrsbek@charter.net  106 Jonathan Reeve From: Sent: To: Subject: kminault@everyactioncustom.com on behalf of Kent Minault Friday, October 11, 2019 3:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.  These cuts would undermine those least able to afford  health care ‐ especially those who already face barriers to care, like people with low incomes, communities of color,  individuals with disabilities, and people in rural areas.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Kent Minault  311 W Glenwood Ave  Knoxville, TN 37917‐5601 kminault@gmail.com  107 Jonathan Reeve From: Sent: To: Subject: apathtochange@everyactioncustom.com on behalf of Linda Weaver Friday, October 11, 2019 3:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Linda Weaver  703 E Maple St  Johnson City, TN 37601‐5811 apathtochange@gmail.com  108 Jonathan Reeve From: Sent: To: Subject: andy.cohen@everyactioncustom.com on behalf of Andrew Cohen Friday, October 11, 2019 3:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Andrew Cohen  Memphis, TN 38104  andy.cohen@riverlark.com  109 Jonathan Reeve From: Sent: To: Subject: norawilliamsmd@everyactioncustom.com on behalf of Nora Williams Friday, October 11, 2019 3:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a psychiatrist who has heard stories of hundreds of patients, I am opposed to the proposal to convert federal funding  for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable  Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like psychiatric  care and psychotherapy, physical therapy, hospice, and transplant coverage without normal federal oversight – and  arbitrarily limit who gets them. The proposal could also cut back on core health care services like hospital care, without  federal approval or public notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Nora Williams  129 Overbriar Dr NE  Cleveland, TN 37312‐5453 norawilliamsmd@mac.com  110 Jonathan Reeve From: Sent: To: Subject: evakrug@everyactioncustom.com on behalf of Eva Krug Friday, October 11, 2019 3:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     These cuts would undermine those least able to afford health care ‐ especially those who already face barriers to care,  like people with low incomes, communities of color, individuals with disabilities, and people in rural areas.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Eva Krug  1804 Linden Ave  Memphis, TN 38104‐6122  evakrug@gmail.com  111 Jonathan Reeve From: Sent: To: Subject: Michael Dioguardi Friday, October 11, 2019 3:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Generally, I support this proposal.  What I see is the state acting as a third‐party payer for qualified people. What I do  not see are the following:    1)  A recognition of the problem created by increased demand for services in a 3rd party payer system in which the users  have no or very little “skin in the game”.  This tends to drive demand for services and thus increase costs for the entire  system.    2)  A methodology for increasing the supply of services and service providers in order to increase competition. This may  have to come in the form of legislation and would then be outside the purview of TennCare.    3)  A means to address increased demand for medical services exacerbated by items such as the 3rd party payer system  listed in item 1, above, but other factors which I can discuss in more detail if needed.  But the primary cause I see is the  nature of any government provided single payer system such as TennCare, Medicare or Medicaid is the fact that to the  user, it is “free”.  A user of a free service not only has an incentive to use as much of the service as possible, they lack the  incentive to make a rational cost‐benefit analysis.  The carrot and the stick in public health insurance is an incentive to  overuse the service rather than make more rational healthcare decisions.  This will tend to drive up expenses to the  maximum allowed under the block grant, leaving the state in a position of either denying services, rationing care or  deficit spending to cover the difference.    4)  A means to address health choices made by individuals which in the aggregate tend to drive up costs.      Michael W. Dioguardi  Nashville  615‐414‐8981    Sent from Mail for Windows 10      To help protect y ou r priv acy , Microsoft Office prev ented auto matic downlo ad o f this picture from the Internet. Virus-free. www.avg.com     112 Jonathan Reeve From: Sent: To: Subject: bord2585@everyactioncustom.com on behalf of Johnny Borders Friday, October 11, 2019 2:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Johnny Borders  PO Box 302  Helenwood, TN 37755‐0302  bord2585@gmail.com  113 Jonathan Reeve From: Sent: To: Subject: sales@everyactioncustom.com on behalf of Karen Tate Friday, October 11, 2019 2:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Karen Tate  6823 Sawyer Rd  Signal Mountain, TN 37377‐1375 sales@watergarden.com  1 Jonathan Reeve From: Sent: To: Subject: elaineysanford@everyactioncustom.com on behalf of Elaine Sanford Friday, October 11, 2019 2:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am categorically opposed to Governor Bill Lee's proposal to change Tennessee’s Medicaid partnership with the federal  government by unfairly converting federal funds for TennCare into a “block grant.” I have worked with recipients of  TennCare for the past eleven years and know firsthand how catastrophic it would be if some of our families suddenly  lost their TennCare coverage.     Since Medicaid was created to help children, people with disabilities, pregnant women, and other struggling Americans  to get the assistance that they need,, why would politicians work so hard to change this?  The block grant initiative  clearly is intended to cut the numbers of people who receive this critical assistance.     Our families are primarily women and children where women are the heads of households.  Many of them are under‐ employed and they don't earn enough from their jobs to be able to pay for housing, utilities, food, clothing,  transportation and, of course, medical needs.   TNCare has been the supplement that has kept many families afloat.   Please do not allow this important lifeline to be taken away.    Why does a Republican‐led Legislature want to do this?  Is anyone reading between the lines? Why was it necessary for  Governor Bill Lee to practically be "coerced" to allow Memphians to offer input which, he knew, would like not support  this harmful effort?  It can only be that this is a political move which does not reflect the feelings or needs of the  majority of people ‐ especially those who would suffer as a result of this action.  If you allow Tennessee to take this  money in grant form, what is to prevent the money from being diverted to other sources?  What prevents it the money  from being used to favor one part of the state as opposed to another?  It seems that to release this money in block grant  form will allow some unscrupulous leaders to play "loose and free" with taxpayer money which ought to have the  assurance of serving those who need it the most.     Please don't allow this to happen. Please don't destroy the only hope left for some women and children.      We respectfully urge you not to say "no" to the block grant initiative.    Rev. Dr. Elaine Y . Sanford  Executive Director  HER Faith Ministries, Inc.  3396 Park Avenue  Memphis, TN 38111  (901) 324‐3705    Sincerely,  Dr. Elaine Sanford  9176 Roundabout Ln  Cordova, TN 38018‐2913 elaineysanford@aol.com  2 Jonathan Reeve From: Sent: To: Subject: hhender@everyactioncustom.com on behalf of Heather Henderson Friday, October 11, 2019 2:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Heather Henderson  126 A Kingston St  Nashville, TN 37207‐4546 hhender@gmail.com  3 Jonathan Reeve From: Sent: To: Subject: Kathleen Rogers Friday, October 11, 2019 11:58 AM PUBLICE NOTICE TENNCARE [EXTERNAL] opposed to block grant funding   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I wanted to share my concern about the proposal to  convert Tenncare into a block grant. There are so many residents in  TN with no coverage currently and this new funding plan would open the door to remove current enrollees and tighten  the eligibility in an effort to prevent covering more Tennesseans in the future. Mental Health treatment providers are so  underfunded‐ and numbers of those needing mental health treatment are growing daily. This is a huge issue that must  be addressed as we work to keep people from hurting themselves or others due to their serious mental illnesses and  their struggle with despair and limited hope for recovery.  I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness,  not hurt them.     Kathleen Rogers, LCSW Director of Quality Improvement p. (615) 463-6655 x. 01-6655 f. (615) 279-6708 1921 Ransom Pl, Nashville, TN 37217 Connect With Us Centerstone         The information contained in this Email message is private and confidential. It may contain Protected Health Information deemed confidential by HIPAA regulations. It is intended only for the use of the individual(s) named above, and the privileges are not waived by virtue of this information having been sent by Email. Any use, dissemination, distribution or copying of this the information contained in this communication is strictly prohibited by anyone except the named individual or that person's agent. If you have received this Email in error, please notify the sender immediately and destroy this Email. Thank You.  4 Jonathan Reeve From: Sent: To: Subject: Bruce Dudley Friday, October 11, 2019 10:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, TennCare is important to my family and loved ones. It provides comprehensive health care coverage for people in need. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare will be of essential help to my daughter when she has to roll off of her mother’s health insurance plan soon. My daughter has a severe mental health disabilty and physical disabilities. It is crucial that she receive the help she will need through TennCare. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness, including my own daughter. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely, Bruce Dudley Nashville, TN 5 Jonathan Reeve From: Sent: To: Subject: marta hernandez Friday, October 11, 2019 10:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare block grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear TennCare officials, TennCare is important to me, my husband Paul and my daughter Jireh. It provides comprehensive health care coverage for people like us that are in need of this program. TennCare is particularly important to children and adults with mental illness, many of whom rely on it to access essential health treatments and manage their condition. TennCare has helped me, my daughter Jireh and my husband Paul by helping us with the prescriptions and our mental and physical health. Without TennCare we will not be able to have a healthy life as prescriptions and doctor’s visits are very expensive. This is crucial for our recovery as if we cannot afford our medications we will not be able to live a healthy life, symptoms will come back and we will relapse. I am concerned about the plan to change TennCare (Tennessee’s Medicaid program) into a “block grant.” This proposal would jeopardize coverage for Tennesseans, particularly Tennesseans with mental illness like me, my daughter Jireh and my husband Paul. I am worried that this proposal would allow the state to eliminate or restrict services that are important to people with mental illness. More people need access to TennCare, not less. I respectfully urge you to reconsider this proposal and focus on solutions that help Tennesseans with mental illness, not hurt them. Sincerely, Marta Hernandez-Fontenot Disclaimer: The information contained in this message, including any attachments, may be privileged, confidential, or  protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an  employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any  6 dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this  communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all  electronic or paper copies of the communication, including any attachments.   7 Jonathan Reeve From: Sent: To: Subject: sleevelessmeeks@everyactioncustom.com on behalf of Joel Meeks Friday, October 11, 2019 12:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    The fact that you would consider this for one second is absolutely insane!    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joel Meeks  3917 Southview Dr  Nashville, TN 37218‐1942 sleevelessmeeks@yahoo.com  8 Jonathan Reeve From: Sent: To: Subject: seejanebike@everyactioncustom.com on behalf of Tammy Hutchison Thursday, October 10, 2019 8:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tammy Hutchison  Nashville, TN 37209  seejanebike@gmail.com  9 Jonathan Reeve From: Sent: To: Subject: hilaryanndaugherty@everyactioncustom.com on behalf of Hilary Daugherty Thursday, October 10, 2019 9:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.     Please consider this. Please act as if your life or someone you love’s life is at stake. Not their money, their life.     Sincerely,  Hilary Daugherty  Watertown, TN 37184  hilaryanndaugherty@gmail.com  10 Jonathan Reeve From: Sent: To: Subject: thosbconner@everyactioncustom.com on behalf of Thomas Conner Thursday, October 10, 2019 9:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Thomas Conner  1312 Falkirk Ct  Nashville, TN 37221‐3625 thosbconner@gmail.com  11 Jonathan Reeve From: Sent: To: Subject: antonella.mour@everyactioncustom.com on behalf of Antonella Marreiros Thursday, October 10, 2019 10:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] STRONGLY Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am strongly opposed to the proposal to To convert federal funding for TennCare into a “block grant.” This proposal  would cause immense harm to my family.    I am a mother. My son has severe hemophilia and depends on life‐giving medicine that we wouldn't be able to afford  even if each one in our families had 10 jobs.    My son has just graduated with all honors from High school and got a full scholarship at Belmont University. He is an  excellent student and works hard to become a scientist. His entire life is around working to be able to contribute to  society.    Without his medicine his dreams would be endangered and so would his life.           TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.    I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Antonella Marreiros  1338 Cardinal Ave  Nashville, TN 37216‐2328 antonella.mour@gmail.com  12 Jonathan Reeve From: Sent: To: Cc: Subject: Kronenberg, Marvin W Friday, October 11, 2019 7:35 AM PUBLICE NOTICE TENNCARE Kronenberg, Marvin W [EXTERNAL] BLOCK GRANT PROPOSAL   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am very concerned that this proposal is more based on financial benefits to the state’s budget and less on caring for medically disadvantaged Tennesseans. Would you, the legislators, or the governor, wish to have this type of health coverage? If not, then it is time to rethink this proposal. Marvin Kronenberg 13 Jonathan Reeve From: Sent: To: Subject: Sharon Jones Friday, October 11, 2019 5:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Governor Lee. This block grant will hurt the working and working poor of our state. We need to expand Medicaid. I have family members whose income was so low dispite working 2 jobs that they did not qualify for the Affordable Care Act and were unable to get on TENNCARE. Shameful. No excuse for a lack of healthcare in this country. My neighbor who did home care and nursery work had trouble getting in TENNCARE when she had an irregular heart beat and weakness. As an RN I’m ashamed I didn’t go and advocate for her. She received minimal assistance from the state of TN and was found dead in her living room age 43. Medicaid would take care of all these problems. TENNCARE is a joke. There are a couple of days yearly people are allowed to apply and it is very hard to get on. PLEASE NO BLOCK GRANTS. Our local hospitals are already closing. Please help make TN a welcoming, caring State to live in that takes care of its own. 14 Jonathan Reeve From: Sent: To: Subject: akatz44@everyactioncustom.com on behalf of Alan Katz Thursday, October 10, 2019 10:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Alan Katz  209 Myhr Grn  Nashville, TN 37221‐2821  akatz44@verizon.net  15 Jonathan Reeve From: Sent: To: Subject: Cathie Buckner Thursday, October 10, 2019 9:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant scares me to death.   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Separation of the State and it’s poor.  Creation of Block Grant  This is what the State is good at:  Throwing 185,000 children off TennCare rolls the year they  want to show the Feds significant savings that this State has  made.  Some mistake?  No on purpose….100,000 of that  purge is still without coverage.    What this State is also good at:  Not increasing or even  opening any enrollment periods for  eligible  TennCare/Medicaid for our children, the disabled,  or for seniors with only social security or those with no  social security at all.   The State proclaimed at the public meetings that this Block  Grant ‘good idea’ will not affect children, those already on  SSI, or the lowest income seniors currently getting the  service.  This is total horse feathers.  I say to that it already  had affected me.  They affect any and every one they can at  16 every chance they get.  This can look like a saving but it is  not.  It causes more emergency room visits and causes for  treatable conditions to balloon into much more expensive  need for care.    This is not our fault.  These children cut off cannot fill out  paperwork and some of their parents can’t either and  sometimes the forms never get there or are discarded amid  the array of junk health care mail we all seem to get.  The  junk mail that these families get for signing up for this plan  or that plan.  Who reads all that?  Not me.   Or do they even  get delivered or the fact that no one may even be home  during mail drop times because of the work or volunteer  requirements The State has put on their parent/s.  The State  has no proof they sent 185,000 letters out.   The fact is it will affect these folks.  The fact that your  hearing was led off by someone representing the State  saying it will not affect these folks.   This is simply further  reason for dis‐trust and dis‐belief.      I say this is not only misleading, it is not true.  I am a  witness.  I was purged from this role in 2013 and was not  allowed by the State to re‐enroll.  The Bureau of Medicare  made the State re‐enroll me when I turned 65.  Because I  17 qualify.  I always qualified.  But for the State I missed the  appeal time and that was that for the State.  I suffered over a year with a prolapsed uterus that got  worse and worse and worse.  It became unbearable but I  could not do anything but suffer because I did not have the  other 20%.  Heaven forbid that I still had Medicare because  I have worked enough to still have that benefit.  In those  years I only went to seek any medical help only twice in that  timeframe…Thank God for minute clinics (which are also  disappearing just like rural hospitals).      This State has more closed rural hospitals than any other  state per capita in the country and the talk is that an  additional savings proposed is to do away with air  ambulance services.    So what do these people do if the magic hour is not going to  be a possibility for them to reach emergency care?  I can tell  you they will die.  How will people with strokes, with heart  attacks, with aneurisms, those in car/bike/pedestrian  accidents, or gun‐shot wounds, or of simply falling, or  preemies or woman with problem pregnancies…what will  they do?    I can tell you, they will die, needlessly.  And The  State will not take on iota of blame.  Lee will ask us to pray  about it.  But he is the one who doesn’t understand.  For his  18 secret meetings with deep pocket folks who have ‘‘a stake’’  in getting the money not one person impacted by these so  called “good ideas” was there. The State scares me to death  because we are last in taking care of the unhoused, our  babies, our hungry children.  We have a doubly higher  infant mortality rate among families in poverty.  And in  region 2 it is double that.  It is terrible to be poor in  Tennessee.  And as I said before I am terrified as to what  this lack of oversite will cause.  The artificial donut hole that  private insurers created to boost their profits will in this  proposed program will be a gaping hole that will simply  write many of us off.  Of all those who spoke, the doctors,  lawyers, priests, parents advocates, even Jim Cooper and  me were all against this.  As it was in the other two  places.  The choices for a place to meet, the way it wasn’t  advertised, the time it was scheduled still for all the good  souls there no Lee, no fat cats with the deep pockets and no  folks who crafted this bill to listen to us.  And the obvious  lack of young mothers, the disabled, the elderly.  The State  did not want them there.   Governor Lee I had a question  but you were not there and no one was going to answer.  My question that you did not let me ask at the meeting is to  know who is the body, organization, or person who will  19 approve or disapprove this Block Grant ‘‘bad idea”?  Please  copy these comments and sent to him/her/them.  Thanks.  Cathie Buckner  615‐973‐1069          20 Jonathan Reeve From: Sent: To: Subject: tfowlkes@everyactioncustom.com on behalf of Tyla Fowlkes Thursday, October 10, 2019 12:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal - regarding Hemophilia patients   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I am speaking on behalf of many patients with Hemophilia, which is a chronic bleeding disorder that can result in  extreme hard, or death, if not treated appropriately. The intravenous medication required to treat Hemophilia, Factor  replacement, is very costly. I have 2 children with severe hemophilia, ages 22 and 13. My 22 year old used $1.3 million  dollars in just factor treatment, not counting physical therapy, ER visits, and regular doctor's appointments for basic care  of his hemophilia. It would be detrimental to their care to have a lapse of insurance coverage, or decrease in the  medication or services available for treatment. It could literally be life‐threatening if not treated appropriately. Without  proper factor treatment, it could also lead to permanent, life‐long joint damage that would cost hundreds of thousands  of dollars in hospital, surgery, and physical therapy costs further down the road. This would also limit their ability to  even be a productive, working adult to stay off of disability. That is the goal of proper treatment. To have healthy joints  and no life‐threatening bleeding episodes.     We have over 400 consumers in Tennessee with hemophilia, or other bleeding disorders. This could be detrimental to  their care and to their actual life. This is not an exaggeration, but real.  I urge you to please consider opposing this  proposal for the sake of Tennesseans rights to the basic healthcare that is life‐saving for them.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,   Tyla Fowlkes  Mom of 2 Severe Hemophilia Patients      Sincerely,  Tyla Fowlkes  1457 Highland Dr  Dyersburg, TN 38024‐8941  tfowlkes@cableone.net  21 Jonathan Reeve From: Sent: To: Subject: debbiesmith0671@everyactioncustom.com on behalf of Deborah Smith Thursday, October 10, 2019 12:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Deborah Smith  2207 Summerfield Ln  Sevierville, TN 37876‐7024 debbiesmith0671@gmail.com  22 Jonathan Reeve From: Sent: To: Subject: johnmwicks@everyactioncustom.com on behalf of John Wicks Thursday, October 10, 2019 12:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. John Wicks  1338 Cardinal Ave  Nashville, TN 37216‐2328 johnmwicks@gmail.com  23 Jonathan Reeve From: Sent: To: Subject: vlbrownutm@everyactioncustom.com on behalf of Vicki Brown Thursday, October 10, 2019 1:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Vicki Brown  Hollow Rock, TN 38342  vlbrownutm@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: hbateman@everyactioncustom.com on behalf of Heather Bateman Thursday, October 10, 2019 3:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I have had (and recently had to release from our care) several Tennessee Medicaid Program recipients that have  hemophilia, a severe bleeding disorder.  Through changes in their Pharmacy program, Tennessee Medicaid caused  reimbursements for these life‐saving drugs to fall to between 2 and 5 THOUSAND dollars less than the cost.  After  keeping patients who were in very vulnerable situations on until they were stabilized (as indigent patients with a  significant loss in revenue), and after reviewing our reimbursement with Myers and Stauffer several times, we ultimately  had to refer them to other pharmacies as we could no longer incur the loss.         Ultimately, another pharmacy that took our patient kept them for less than two months before offloading them for a  similar reason.  Meanwhile, this pediatric patient is left in limbo as to how/when/where they will be able to get their life‐ saving medication.         This is a real problem for Tennessee Medicaid, and I honestly fear for the lives of these patients, who are already our  most vulnerable and now are having to also try to fight for themselves.   If changes need to be made with this program,  it is only the administration that is in charge of this program and these decisions.   I truly hope you fix these issues  before patient deaths are placed squarely in your lap‐‐because that will be the next situation.     Sincerely,  Mrs. Heather Bateman  7856 Westside Park Dr  Mobile, AL 36695‐8541 hbateman@familyfactor.net  25 Jonathan Reeve From: Sent: To: Subject: Rgadupree Thursday, October 10, 2019 3:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment to convert Tenncare to Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am vehemently opposed to the proposal to change Tennessee’s Medicaid partnership otherwise known as Tenncare into a “block grant.” This proposal is poised to jeopardize coverage for vulnerable Tennesseans. I work with fragile families who need sound stable Medicaid supported by the federal government. They do not need a TN version that will have restrictions and rules that would end numerous patient protections. Services such as mental health, hospice and transplant coverage would all be in jeopardy or elimination .As a taxpayer I am already paying into the Medicaid program, but because the state legislature and the governor have refused it, other states are able to access that money. I do not think this is fair. Without federal oversight in our society women,minorities and other marginalized populations would be victims of "states rights" policies and practices. I am very clear of the fact that this proposal would hurt certain populations more than others. It is simply criminal and a disgrace. Tenncare needs more accountability not a watered down version created by politicians that want to boast low numbers of families on medicaid. I attended the public comment meeting in Jackson, TN and the group of about 50 people overwhelmingly were opposed to this proposal. I urge the governor, legislators and other decision makers to listen to the voice of the people and stop this proposal now. Robin Gadsden-Dupree 1928 Jennings Road Alamo, TN 38001 26 Jonathan Reeve From: Sent: To: Subject: mesneed1942@everyactioncustom.com on behalf of MARY SNEED Thursday, October 10, 2019 8:13 AM PUBLICE NOTICE TENNCARE [EXTERNAL] This is a terrible idea and totally against what TennCare was developed for. Please vote against this!!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  MARY SNEED  2150 Sams Creek Rd  Pegram, TN 37143‐5042 mesneed1942@gmail.com  27 Jonathan Reeve From: Sent: To: Subject: rnknlstr@everyactioncustom.com on behalf of Sue Rankin-Lustre Thursday, October 10, 2019 10:13 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Sue Rankin‐Lustre  802 Mills Creek Ln  Cookeville, TN 38501‐3700 rnknlstr@yahoo.com  28 Jonathan Reeve From: Sent: To: Subject: Atudonlife@everyactioncustom.com on behalf of Carol Smith Thursday, October 10, 2019 11:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    10/9/2019                                                                                                                    My name is Carol Smith. I’m 43 years old and I have Cerebral Palsy. I have to depend on someone for my daily needs. I  can’t do anything for myself. Dad and Mom took care of me by themselves for 36 years. I remember when I got my lift to  help mom lift me, My TennCare insurance said no Dad and Mom had to go before a judge to get it paid for. The judge  order them to pay for it and to put a CNA. In our home to help my mom with me because mom was getting weaker from  a muscle diseases, that she inherited from her mother.  It has been one fight after another. I really don’t understand  why TennCare has to be that way. They spend more money trying to keep families from getting the things they need  than they do helping families. Why is that we just don’t understand? We’ve never ask for things that I didn’t need. We  ask for things that doctors said I needed to help me get stronger. No matter what it was TennCare said I didn’t need it. It  was not like my parents and I were doing it for the fun of it. I sure wished I could have changed places with the people  that kept saying no. Then they could have seen how it was to have to depend on them to approve a new wheelchair or  bath chair. I would rather be doing something to help someone, than fighting with TennCare because that is so stressful.  It has always been a real struggle for me to get things I’ve needed to survive in the real world. Life is so unfair.    I’m really scared about the state going to block grants. If we’ve had to fight this hard with TennCare. What will it be with  block grants? They will cut people like me and my mom off. The Medicaid block grant targets TN’s sickest patients. The  block grant weakens account‐ability of government and is an invitation to fraud and abuse by managed care contractors.  Not only would the state get a pass, but so would its managed care organizations (MCOs) Twenty years ago, TN  experienced firsthand the abuse and cronyism that this proposal now invites. Shoddy contractors failed to provide care  to patients, taxpayers were ripped off, and providers were left unpaid. Do we really want to go back to this?    TN has serious healthcare challenges. Declining insurance coverage among children.  Nation’s highest rate of rural  hospital closures, Overdose epidemic, Medical debt Threats to people with pre‐existing conditions. TennCare is the last  state agency that should be given a blank check. That would be like turning a child loose in a toy store with a blank check  and telling them they could buy what      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.   29   This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Carol Smith  306 Plaza St  Knoxville, TN 37920‐4067  Atudonlife@aol.com  30 Jonathan Reeve From: Sent: To: Subject: aunna@everyactioncustom.com on behalf of Francisca Carr Thursday, October 10, 2019 11:22 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Francisca Carr  Clarksville, TN 37042  aunna@yahoo.com  31 Jonathan Reeve From: Sent: To: Cc: Subject: Pam Millsaps Thursday, October 10, 2019 9:32 AM PUBLICE NOTICE TENNCARE Pam Millsaps; Bill Freeman [EXTERNAL] Block grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Greetings: as a mental health practitioner in Tennessee who serves Tenncare clients, I would like to comment on the block grant proposal in TN. With the block grant proposal, which no other state is doing, Tennessee continues its war on the poor and sick. Tenncare originally was a compassionate take on Medicaid to provide medical and mental health support for the most vulnerable in our state. Efforts to chip away at it, mostly by Republican administrations, are causing death and misery in TN when it is not necessary. In fact, it can be seen as genocide on the poor and sick. Any one of us, except for Bill Lee, it seems, could be found in a situation where we may need Tenncare services due to disability. Even children here are prevented from having medical and mental health treatment they need since Tennessee did not expand Medicaid for low income working families. I urge this administration to stop its attack on the poor and sick and to provide benevolent care for our most vulnerable citizens, including children. Respectfully, but pissed off, I am Pamela Gard Millsaps in Athens, TN. 32 Jonathan Reeve From: Sent: To: Subject: kmmehner@everyactioncustom.com on behalf of Karen Mehner Wednesday, October 9, 2019 9:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     As a Tennessean, this would affect me personally, in a very negative way.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Karen Mehner  Butler, TN 37640  kmmehner@gmail.com  33 Jonathan Reeve From: Sent: To: Subject: meryl.rice@everyactioncustom.com on behalf of Meryl Rice Wednesday, October 9, 2019 9:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a retired psychotherapist. For all of my years in the field, the agencies I have worked for accepted Medicaid  reimbursement at 35%. That was bad enough, now you want a block grant with NO federal oversight. How can I trust  that you are going to spend this money for the purpose it was intended? Furthermore you save 2 million and you get to  split it with the feds‐‐so you have a incentive to pay less in benefits or throw people off. BTW, I now enroll people in  Tenncare. Everyday I get calls from people who were cut off for no known reason. These folks don't understand  computers and the Tenncare number and all the prompts are even hard for me to figure out. I somehow think that is  intentionally hard to discourage people from re‐applying. It's always about hurting the least of these. Very sad. And to  top it off, block grants don't even address the medicaid gap or our rural hospitals closures. Only medicaid expansion  would have helped that, and Repubs will never let that happen.           Sincerely,  Meryl Rice  5690 Old Highway 64  Whiteville, TN 38075‐8404 meryl.rice@gmail.com  34 Jonathan Reeve From: Sent: To: Subject: donaldwatkins01@everyactioncustom.com on behalf of Donald Watkins Wednesday, October 9, 2019 11:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Disability Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.   We also would like for Tennessee to accept the Medicaid expansion, and reopen our rural hospitals.    Sincerely,  Mr. Donald Watkins  Saulsbury, TN 38067  donaldwatkins01@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: bj.snell@everyactioncustom.com on behalf of Barbara Snell Wednesday, October 9, 2019 4:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal OBJECTION   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Barbara Snell  Gallatin, TN 37066  bj.snell@comcast.net  36 Jonathan Reeve From: Sent: To: Subject: ryanlloyd1212@everyactioncustom.com on behalf of Ryan Lloyd Wednesday, October 9, 2019 6:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Ryan Lloyd  26 E Main St Apt 325 Chattanooga, TN 37408‐1256 ryanlloyd1212@gmail.com  37 Jonathan Reeve From: Sent: To: Subject: aef03@everyactioncustom.com on behalf of Adrienne Frey Thursday, October 10, 2019 8:24 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Adrienne Frey  403 Stable Dr  Franklin, TN 37069‐4138  aef03@bellsouth.net  38 Jonathan Reeve From: Sent: To: Cc: Subject: Anne Ramsaur Wednesday, October 9, 2019 8:24 PM PUBLICE NOTICE TENNCARE; Anne Ramsaur Anne Ramsaur [EXTERNAL] The Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Please! Consider why TennCare exists.     The family I work for depends totally on TennCare funds to care for a totally disabled woman and her completely  disabled daughter at home where they belong as a family who works so hard to keep them alive.     I invite you to their home to see for yourselves. They will welcome you. See how TennCare gives a 74 year old husband  and father the help he needs to care for his disabled family. He already cooks, cleans, shops, drives them to  appointments and everything else needed to run a home and keep a van working. They have no night help. He is often  up at night with them. TennCare provides daytime care for each of the women. The family is grateful. The family is  fearful. They cannot afford to lose any help at all.     I witness a tremendous waste of supplies that are often automatically sent. Supplies they need don’t always get there.  Supplies they don’t need have been sent repeatedly. Another family in the neighborhood recieves supplies not needed.  They tried to stop the supplies from being delivered. They couldn’t. They had a garage full of diapers they gave to  charity!!     Let’s look at the terrible mismanagement of supplies here. Someone is making a fortune, folks!! Wake up to this.     Don’t make the vulnerable disabled and their hard‐working families shoulder even more. This will break their backs!     They need TennCare desperately. Please say it ain’t so, legistlators! If you have not visited a home where the most  incredible fight for life goes on quietly and desperately, your decisions will not be made based on need at all, but  perhaps based on something political or pressured by someone political.     Who really gets the breaks here? People with legitmate need? People who can barely find energy to speak up for  themselves, or can’t speak at all?     Or...is this something that benefits the legislators?     That, my good people, is my question.     Thank You for your consideration.   I choose to speak for those who are unable.    Anne Ramsaur     Sent from my iPhone  39 Jonathan Reeve From: Sent: To: Subject: Lloyd, Ryan Wednesday, October 9, 2019 6:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Upcoming Legislation   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To whom it may concerns,  I am writing to you as a social worker and a Master's Social Work student at UTK that I am in opposition to the Medicaid  Block Grant Proposal. Please do not pass anything that will affect our most vulnerable people.  Ryan Lloyd  40 Jonathan Reeve From: Sent: To: Subject: jstephen@everyactioncustom.com on behalf of Jeanie Stephenson Wednesday, October 9, 2019 1:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jeanie Stephenson  Decherd, TN 37324  jstephen@sewanee.edu  41 Jonathan Reeve From: Sent: To: Subject: Jsmith5799@everyactioncustom.com on behalf of Jean Smith Wednesday, October 9, 2019 2:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Hello: To Whom This May Concern                                               10/8/2019    My name is Jean Smith, I’m the mother of a Daughter that has Cerebral Palsy. She requires 24 hour care. My husband  and I took care of her without any help until 2008. Then things changed because I have a form of Muscular dystrophy  that effect my whole body. I only have two fingers That I can use on my left hand It’s a struggle for me to type this  article. I have to do this because it really stresses me out to think that Tennessee might go to block grants. It really  scares the life out of me. Over the years it has been a battle every time we’ve needed something. TennCare always says  no. Health care shouldn’t be that way. My Daughter and I are both on TennCare, I would rather be able to work but I  can’t because this disease is slowly taking the use of my  body away. I can’t imagine how things will be if Tennessee is  allowed to go with block grants.  I’m telling you it is really a problem to get the services that we need and it been that way for years. Tennessee needs to  be held account‐abie for how they do health care. As a mother  that’s dealt with this for over 30 years. I’m asking please  don’t allow block grants to go in effect in Tennessee for the sake of families.    The state’s TennCare block grant proposal puts coverage and services at risk for vulnerable Tennesseans. The proposal  would give Tennessee new authority to cut services for children, low‐income parents, and people with disabilities. Under  the proposal, the state could: eliminate or restrict services like physical therapy, hospice, and transplant coverage  without normal federal oversight  and arbitrarily limit who gets them, cut back on core health care services like hospital  care and emergency services, without federal approval or public notice, allow Medicaid managed care plans to restrict  access to needed care, and exclude coverage of high‐cost prescription drugs.     TennCare is the last state agency that should be given a blank check. Rather than Insuring all vulnerable Tennesseans  who are eligible for TennCare are getting the vital medical services they need, TennCare has systematically kicked  children and people with disabilities off their health coverage. Over the past two years, TennCare cut off 200,000  children, the great majority of whom were still eligible. People on Social Security pensions, whose Medicare premiums  are paid by TennCare if they have low incomes, continue to suddenly find money taken out of their Social Security  checks because TennCare has mistakenly stopped making the payments. TennCare needs more accountability, not less.     The block grant does nothing to address the real health concerns of Tennesseans, In fact it would make things worse. TN  has some of the most daunting challenges facing any state, including being among the worst in declining insurance  coverage of children and rising rate of rural hospital closures. Rather than adequately addressing the real concerns of  Tennesseans, politicians have instead seized on the block grant as a distraction from their failure to come up with real  answers to our real and urgent problems. Not only that, State leaders have said that the goal of the block grant is to take  $2 billion out of Tennessee’s healthcare system. The state’s principal goal is for the state to obtain “upwards of $1  billion” in so‐called "savings," according to Gov. Lee. Since TN will only keep half of the money saved (with the other half  going to the federal government), that means the state is aiming for a total of $2 billion in cuts. The block grant proposal  would enable the state to divert funds from the health care system and spend the money however it chooses. It’s a  42 transfer from patients and providers to the state and federal governments. Please don’t let this happen. I’ve worked  hard all my life and paid taxes we shouldn’t have to keep fighting for health care. Thank you for reading this.    Jean Smith‐ Jsmith5799@aol.com        Sincerely,  Mrs. Jean Smith  306 Plaza St  Knoxville, TN 37920‐4067  Jsmith5799@aol.com  43 Jonathan Reeve From: Sent: To: Subject: drbarger@everyactioncustom.com on behalf of david barger Wednesday, October 9, 2019 2:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] tncare     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,         Two options face Tn with regard to health care.  The first is Gov. Haslam's Insure TN.  This is similar to that which has  been accepted by many states, wherein more Federal dollars are secured to operate the system.  The Medicaid Block  Grant proposal as described is hoped to "transform" the TN medicaid delivery system while producing "significant value"  to the state and the Fed by managing program growth.  This despite significant cost overruns by the Tncare eligibility  determination system.         TNcare has already been one of the nation's cost effective programs and Amendment 42 refers to TN's history of  "prudent and effective management".  The TN 115 demonstration waiver "underspends" the Fed budget neutrality cap.   By accepting the block amendment and using the Fed's projections how is it possible to spend much less than currently?   The cost saving "flexibility" of the State has not been defined , nor have other designated benefits of the block such as  private consumer empowerment and member engagement.  Community based solutions, prevention and wellness, and  provider competition are estemed goals but again are not detailed.       Is this best for TN?  Overspending should be avoided but underspending will rarely be forgiven.                                                                                                                                                      Respectfully,                                                                                                                                    David R. Barger    Sincerely,  Dr. david barger  17950 Dodson Branch Hwy  Cookeville, TN 38501‐9532 drbarger@netscape.net  44 Jonathan Reeve From: Sent: To: Subject: iammarycharles@everyactioncustom.com on behalf of Mary Charles Davis Wednesday, October 9, 2019 10:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.        Sincerely,  Mary Charles Davis  1201 Stratton Ave  Nashville, TN 37206‐2715 iammarycharles@gmail.com  45 Jonathan Reeve From: Sent: To: Subject: truestorypictures@everyactioncustom.com on behalf of Joann Selvidge Wednesday, October 9, 2019 10:02 AM PUBLICE NOTICE TENNCARE [EXTERNAL] My Family Opposes Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, like my daughter Frannie (8) and my son Stevie (5), who has Prader Willi  Syndrome.    If your child had a debilitating chromosomal disorder, wouldn't you want him to get all of the services and support that  he needed to thrive? An expansion of Medicaid would guarantee those services ‐ especially in cases like ours, where we  have a limited ability to pay for additional services he needs. But the BLOCK GRANT would cut corners, restrict and cap  funds, and be a blockade for poor families to be able to do what rich families don't even think twice about: getting their  children everything they need ‐ especially when it comes to health care.     When Stevie was born, TennCare botched our application and denied him ‐ even though his older sister was already  covered by TennCare. After all of the appeals we ended up suing TennCare to do the right thing. After 18 months of  fighting for coverage during his most precarious period of medical needs, TennCare said it made a mistake and  reinstated our full coverage, once Tennessee Justice Center got involved. During this timeframe, when Stevie was 13  months old, he started taking Human Growth Hormone shots (which we give him daily to improve his muscular and  cognitive development). Because of these shots, he was finally able to start walking independently at age 2, and at age  5, he can experience Kindergarten in a "typical" classroom, with special needs support. These HGH shots are well beyond  our price range to afford as a family, and thankfully, now, TennCare covers them for Stevie. Our fear with BLOCK  GRANTS is that with capped services ‐ while he could possibly be able to continue his HGH therapy, but his weekly  therapy appointments for Occupational, Physical, and Speech therapy could be reduced or cut back, or worse, capped  entirely. Is this what you would want for your child?? Partial services for a lifetime of disability?    To make matters worse, this past year, our daughter Frannie's TennCare services were suspended due to paperwork  issues. Eventually we were able to get her coverage reinstated, but these burdens on a working family that is clearly  eligible for services take advantage of the poverty and lack of transportation that many families face in order to "save  State money" by cutting children off from their health care. This is immoral and sadistic. I personally experienced it as  punitive & poverty‐shaming.    Medicaid was created to help children, those with disabilities, pregnant women, & other vulnerable Americans get vital  health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     46 TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place to protect our vulnerable. Without  such guardrails, the state could return to the days when managed care contractors failed to provide care to patients and  providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital health coverage  for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Joann Selvidge  316 Hawthorne St  Memphis, TN 38112‐5315 truestorypictures@gmail.com  47 Jonathan Reeve From: Sent: To: Subject: sheilakethley7@everyactioncustom.com on behalf of Sheila Kethley Tuesday, October 8, 2019 9:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Tennessee has not earned less oversight   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     We are failing our rural citizens by allowing their hospitals to close. We are failing our vulnerable children by removing  them from Tenncare and letting their parents think they did something wrong. Our leaders need to think about what our  citizens need, and not spend so much effort trying to be the ALEC poster child or the darlings of the Tea Party. Sincerely,  Sheila Kethley RN    Sincerely,  Sheila Kethley  Murfreesboro, TN 37130  sheilakethley7@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: MILLIESWEENEY@everyactioncustom.com on behalf of Millie Sweeney Tuesday, October 8, 2019 4:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. It is obvious that Tennesseans do not want this based on the ZERO lack of support  for the waiver during opportunities for public comment.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.  This will lead to further hardship and health issues for  the most vulnerable of our citizens.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Millie Sweeney    Sincerely,  Millie Sweeney  2444 Pleasant Springs Ln  Hermitage, TN 37076‐1399 MILLIESWEENEY@YAHOO.COM  49 Jonathan Reeve From: Sent: To: Subject: keelysage@everyactioncustom.com on behalf of Keely Sage Tuesday, October 8, 2019 8:43 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Keely Sage  Knoxville, TN 37920  keelysage@hotmail.com  50 Jonathan Reeve From: Sent: To: Subject: angelique.k.axelrode@everyactioncustom.com on behalf of angelique axelrode Tuesday, October 8, 2019 5:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  angelique axelrode  2312 Elliston Pl  Nashville, TN 37203‐5259 angelique.k.axelrode@vanderbilt.edu  51 Jonathan Reeve From: Sent: To: Subject: melissa.mckinney@everyactioncustom.com on behalf of Melissa McKinney Tuesday, October 8, 2019 11:20 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Melissa McKinney  947 Greerland Dr  Nashville, TN 37204‐4052 melissa.mckinney@comcast.net  52 Jonathan Reeve From: Sent: To: Subject: russanne@everyactioncustom.com on behalf of Russanne Buchi-Fotre Tuesday, October 8, 2019 10:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Russanne Buchi‐Fotre  3005 Blakemore Ave  Nashville, TN 37212‐3325 russanne@comcast.net  53 Jonathan Reeve From: Sent: To: Subject: Wayne Dowdy Tuesday, October 8, 2019 8:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenncare Block Grant Public Comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Director Roberts:    I am writing to comment on the proposal to seek a portion of federal medicaid funds for Tenncare in the form of a block grant. It concerns me that when we discuss this issue we focus only on the number of participants, the amount of money available and the number of those not eligible for coverage. In all our discussions we never give a name and face to those who are affected by our decision.     Mr. Derrick Patterson of Memphis is one of those who currently benefits from Tenncare and who may lose his healthcare coverage if the block grant proposal is adopted. Derrick has been diagnosed with an intellectual disability and in 2017 he was enrolled in the Employment and Community First CHOICES program, which has provided him with health insurance and employment assistance. Because of this Tenncare program, Derrick’s health has improved, and he has been employed at Autozone since January, 2018. In addition, Derrick is dedicated to his community - for five years he has volunteered at the Memphis Public Library, Autism Resources of the Mid-South, St. Jude Children’s Research Hospital’s Ronald McDonald House and Le Bonheur Children’s Hospital. Shortly before his death, President George H. W. Bush honored Derrick with the Daily Point of Light Award.     I fear that the block grant proposal will end up denying people like Derrick the health care they so desparately need. When we do this, we refuse them a place in the building of our nation, we stain them with a mark of worthlessness, and our fragile community is weakened by their absence.     We Tennesseans must ask ourselves - what is to become of the many Derrick’s living among us who do not receive adequate health care and therefore are prevented from contributing to and participating in society? What is to become of the rest of us who do not benefit from the skills and talents of the many Derrick’s in our state?      G. Wayne Dowdy  3574 Marion Avenue  Memphis TN, 38111    54 Jonathan Reeve From: Sent: To: Subject: Teresa Beamon Tuesday, October 8, 2019 5:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Admendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am contacting about the new amendment I pray that I am keeping my tenncare because without it I want make I  cannot afford to pay for the medication that is necessary for me to take so please do not take my insurance.  55 Jonathan Reeve From: Sent: To: Subject: Madeline Garr Tuesday, October 8, 2019 5:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Response to Block Grant Proposal Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern:  I am writing in response to the request for public comment regarding the Division of TennCare TennCare II  Demonstration, Project No.11‐W‐00151/4, Amendment 42 also known as the Block Grant Waiver.  1. 2. 3. 4. 5. I want to make it clear that:  I have read the actual Waiver;  I am an educator with a MA and also have a Linguistics background;  I am a native Tennessean;  I am a Certified Application Counselor and have served as a volunteer to enroll fellow Tennesseans into  the ACA or TennCare since 2013;   6. I worked as a Wellness Coach for 7 years with Vanderbilt University in service to both faculty and staff;  7.  I have had over 20 years’ experience working with people who have needed the services of TennCare,  most recently through my work with the ACA and fielding calls for the last seven years.  I believe that this background gives me the gravitas to make the following comments.  Several issues struck me as I studied the Amendment 42 waiver.  I have concerns about these issues:   1.  The wording of the document, particularly the consistent use of the variations of the word “flexibility”, “innovation”,  “incentive”, “effective”, and “other considerations” is vague and is distracting.    “Flexibility” can mean anything.  “Innovation” just signals something new, not necessarily better.  “Incentive” just means  a motivating force that can produce any type of behavior, “effective” depends on who is judging what effective looks  like, and “other considerations” creates a question regarding what other considerations are being considered.    In a document of this import, the usage of these words and phrases read more like spin and advertising than a serious  description of the issue.  2.  In addition, this document is, for lack of better word, a series of complaints about the current processes and  requirements of the Federal Government and CMS regarding their oversight and regulatory requirements of the current  TennCare program and the desire to eliminate these constraints in the TennCare II Demonstration, as is detailed in the  draft of this document.  The tone seems to be concerned with criticizing the processes, procedures, and required  regulatory oversight.  As an educator, I can’t imagine what learning would look like without processes, procedures, and  oversight. Why would the state want to abolish these?  Without these federal requirements, the safety net for those  who desperately need it could, and probably, would be compromised for the sake of profit and power.  56 3.  TennCare has improved immeasurably since its inception.  It is one of the most cost‐effective Medicaid programs in  the nation.  As of 2018, it delivered care to 1,347,068 Tennesseans, 20.1% of the population of Tennessee.  In doing so, it  has saved lives and resources and improved the health and well‐being of many in our state.     TennCare has also saved the federal government money.  This is a good outcome.  We all belong to a country called the  United States of America.  The welfare of each of us as individuals, of our individual states, depends on the overall  resources and welfare of our country.  In 2019, Tennessee has received a 65.87% match from the federal government  for its TennCare program.  Although some states (West Virginia, South Carolina, New Mexico, Mississippi, Kentucky,  Idaho, District of Columbia, Arkansas, and Alabama) receive between 70 and 74.34% match, 25 of our sister states  receive less than a 60% match for their Medicaid programs.  Basically, the money TennCare “saves” contributes to the  welfare of those states who are less fortunate than we are.     4. This emphasis in the document on the concept of “saving money” is also disturbing. Since 2013, Tennessee has  knowingly turned down billions from the Federal Government which could have been and still could be used to expand  Medicaid in the state.  Billions!!!!  This decision has affected the health and welfare of our state. Our economy,  particularly the economy in the rural areas, has been impacted negatively.  Hospitals have closed which means that  medical practices have relocated.  Patients have suffered.  Meanwhile, more than 300,000 Tennesseans remain  uninsured and that number has increased in the last year.     I have talked to many of these fellow Tennesseans. Who are they? You may ask.  They are those people who do NOT  meet eligibility requirements of the TennCare Categories.  They are often folks between 50 and 64 who have worked all  of their life but have either been injured on the job or have a health condition which prevents them from full time  employment thereby causing them to fall below 138% poverty level.  They are folks that have fallen into the GAP  because of political decisions and bias.  Most are white and most are rural.  They have no good options.     The document also states on page 12 that “ …the state is in a better position than the federal government to direct  TennCare spending in order to most effectively promote the health of the TennCare population.”  According to  americashealthrankings.org, Tennessee, ranks 41st out of 50 states in health outcome data in the health of women and  children and was 44th in overall health ranking in 2016.  These statistics speak to three issues:  a.     Although TennCare may have improved, there are still vast issues with the health of those covered.  b.     Not expanding Medicaid has not improved the health of Tennesseans at large.    c.     “Saving money” should not be a goal, particularly if we are rejecting money with one hand and grabbing it  with another.     5.  In general, money and trying to avoid any accountability to the Federal Government seems to be the general theme  of Amendment 42.  Though resources are important, the mission of TennCare is to act as a safety net and provide  medical access to those who need it. The mission of TennCare is not to save money.  The role of the Federal Government is to provide oversight and regulatory accountability. This protects those in the  safety net and the safety net itself.  There is much discussion about having flexibility to be innovative.  What does this  look like? Telemedicine in areas of the state where cell phones do not work, where there is one dial up access point in a  county, where you turn left off of I40 and there is no coverage? How does Telemedicine work in those  areas?  Telemedicine doesn’t help when a person has had a heart attack or stroke and there is no hospital or ambulance  service in the rural vicinity. What about the payment options?  What happens if you are uninsured or not eligible for  TennCare?  What if your insurance doesn’t pay for Telemedicine?  So much for flexibility and innovation.  6.  On page 13 of the Draft Proposal, there is a heading Investing in Health, Not Just Healthcare.  From seven years of  experience working at Vanderbilt as a Wellness Coach, I can say wholeheartedly that this sounds great but is very  difficult.  Helping people exercise, quit smoking, eating healthy, reduce stress, and lose weight is a mammoth task and a  cultural challenge.  The CDC has had this goal in focus since 2010.  For more information on this topic, I refer you to  57 https://www.cdc.gov/nchs/healthy_people/hp2010.htm  At this website, you will see plans for 2020 and  2030.  Obviously, the goal of Investing in Health, Not Just Healthcare is laudable, but I question the plan to use block  grant funds when efforts are ongoing in Public Health to achieve these goals and when 300,000 Tennesseans have no  access to healthcare at all.  7.   The Draft Proposal makes it clear that Outpatient Prescription Drugs, among others, are excluded.  The Draft  Proposal also states on Page 3 that the proposal does not rely on reductions to eligibility or benefits to achieve the  savings it requests.  Yet, on page 14, the pharmacy benefits are addressed as if they were a part of the Block Grant  Proposal and the state is proposing that it have flexibility under the demonstration to adopt a commercial‐style closed  formulary with at least one drug available per therapeutic class.  This is contradictory to the concept that Outpatient  Prescription drugs are excluded from the Draft Proposal.  In like manner, on page 20, there is much discussion regarding  flexibility requested for the state to make changes to the benefit package, whether optional or mandated covered  benefits.  Once again, the stated position on Page 3 is contradicted on page 20.   8.   Finally, I question who will be making decisions.  One of the most sacrosanct relationships one can have is the  relationship between the medical provider and the patient. This relationship has eroded over the last decade but  remains important in the minds of most people.  Decisions about medical care, drugs, procedures, etc.  should be made  by qualified medical personnel and the patient, not by state officials, state legislators, insurance personnel, or outside  entities.  The entire tone is “let us decide for you”, something I doubt the authors/supporters of this document would  want to happen to them or their families.  It is paternalistic and arrogant.    As you can see from the points iterated above, I am not in favor of this Block Grant Amendment 42 proposal.  I ask that  it be abandoned or if not abandoned, that it be rewritten to address fact, not opinion, reality, not spin, affordable and  accessible healthcare for all Tennesseans, not money spent or saved.   In that way, maybe our health outcomes will  improve, more Tennesseans will have access to healthcare, and Tennessee will become more economically sound.    Sincerely,  Madeline B. Garr  259 Graylynn Drive  Nashville, TN 37214  615‐305‐5073               58 Jonathan Reeve From: Sent: To: Subject: rlizsanford@everyactioncustom.com on behalf of Rebecca Hernandez Tuesday, October 8, 2019 4:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    Please stop this proposed change to the TN Medicaid partnership with the federal government converting funding into a  “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans. I work  with a number of clients on TennCare and hear firsthand how important this is to those families.    Medicaid helps needy children, people with disabilities, pregnant women, and other vulnerable Americans get vital  health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rebecca Hernandez  Nashville, TN 37206  rlizsanford@gmail.com  59 Jonathan Reeve From: Sent: To: Subject: grannytish01@everyactioncustom.com on behalf of Pat Tabor Tuesday, October 8, 2019 12:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Pat Tabor  406 Mckinney St  Estill Springs, TN 37330‐3032 grannytish01@gmail.com  60 Jonathan Reeve From: Sent: To: Subject: rl@everyactioncustom.com on behalf of Robbie Hunsinger Tuesday, October 8, 2019 1:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Robbie Hunsinger  4021 Ivy Dr  Nashville, TN 37216‐2917  rl@robbiehunsinger.com  61 Jonathan Reeve From: Sent: To: Subject: RICHARD GUIDEN Tuesday, October 8, 2019 4:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   NO. Far too many people in the state of TN do not have healthcare. First, the legislators want to get rid of the Affordable Care Act which will reduce coverage for those who need it. Second, Medicaid expansion, which would increase the amount of those covered has also been rejected by our legislators. So now our legislators, and Governor Lee, think they can make some money by Block Granting our Tenncare system. And the only way to make that money is to reduce coverage to the lowest common denominator. The less it costs TN the more money we get into our coffers. There is absolutely No incentive to expand or increase coverage to those presently not served yet in need. While Gov Lee says that with the savings there "may be opportunities to expand coverage" there is NO definitive plan proposed to hang a hat on. Promises made, promises broken is not good policy. Richard D. Guiden Old Hickory TN 62 Jonathan Reeve From: Sent: To: Subject: Dayleelou@everyactioncustom.com on behalf of Dayle Morse Tuesday, October 8, 2019 3:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal. From West TN     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. All that and what happens at around the end of  the year or about this time of the year when people start getting sick and there's no more funds because of the amount  that got spent the beginning of the year when the weather changed and so many were sick then too.... And still had the  disabled to deal with...    Sincerely,  Ms Dayle Morse  Puryear, TN 38251  Dayleelou@gmail.com  63 Jonathan Reeve From: Sent: To: Subject: blairemorriss@everyactioncustom.com on behalf of Blaire Morriss Tuesday, October 8, 2019 7:01 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Blaire Morriss  1720 Beechwood Ave  Nashville, TN 37212‐5502 blairemorriss@gmail.com  64 Jonathan Reeve From: Sent: To: Subject: gloria.j.hausser@everyactioncustom.com on behalf of Gloria Hausser Tuesday, October 8, 2019 8:36 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Gloria Hausser  222 Plantation Ct  Nashville, TN 37221‐7401 gloria.j.hausser@gmail.com  65 Jonathan Reeve From: Sent: To: Subject: joannemartin37221@everyactioncustom.com on behalf of Joanne Martin Tuesday, October 8, 2019 10:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joanne Martin  Nashville, TN 37221  joannemartin37221@gmail.com  66 Jonathan Reeve From: Sent: To: Subject: jharkey@everyactioncustom.com on behalf of John Harkey Tuesday, October 8, 2019 9:52 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. John Harkey  225 Craighead Ave  Nashville, TN 37205‐2543 jharkey@harkeyresearch.com  67 Jonathan Reeve From: Sent: To: Subject: jmcorwin@everyactioncustom.com on behalf of Jennifer Corwin Tuesday, October 8, 2019 9:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Jennifer Corwin  4121 Elder Pl  Nashville, TN 37215‐1732  jmcorwin@hotmail.com  68 Jonathan Reeve From: Sent: To: Subject: jazlin.dubon@everyactioncustom.com on behalf of Jazlin Dubon Tuesday, October 8, 2019 11:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jazlin Dubon  104 Westchester Ct  Madison, TN 37115‐3438 jazlin.dubon@icloud.com  69 Jonathan Reeve From: Sent: To: Subject: katehans@everyactioncustom.com on behalf of Kathryn Hansen Tuesday, October 8, 2019 7:40 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathryn Hansen  5230 Old Hickory Blvd  Nashville, TN 37218‐4303 katehans@gmail.com  70 Jonathan Reeve From: Sent: To: Subject: Jo-Ann Murphy Tuesday, October 8, 2019 2:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Gov. Lee s Medicaid Block Grant plan     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐    Gov. Lee’s Medicaid Block Grant plan will jeopardize health coverage for over 1 million Tennesseans TennCare  recipients, including children, low‐income parents, and people with disabilities, it does not extend coverage to every  person in Tennessee!    Governor Lee’s block grant plan would cap the amount of federal funding, also known as our tax dollars coming back to  our state, that the state receives for TennCare.    Gov. Lee’s Medicaid Block Grant plan would exclude Tennessee from federal Medicaid standards that protect patients  and ensure the funding is being used appropriately, allowing the state to arbitrarily cut eligibility and benefits.  There is  NO ACCOUNTABILITY.  It would allow politicians like Bill Lee to randomly decide what coverage to restrict or eliminate  for services like physical therapy, occupational therapy, hospice, and transplant coverage    It would allow politicians to arbitrarily limit who gets certain services Governor Lee’s block grant plan would also  completely eliminate federal standards.    No other state has sought a Medicaid block grant, and for good reason ⁠— it does nothing to improve access to  care and only stands to strip health care from Tennessee’s most vulnerable citizens in the event of an unexpected rise  health care costs.    Medicaid expansion remains the number one most impactful step we can take to expand coverage for uninsured  Tennesseans and address our public health crises spurred by hospital closures and the opioid epidemic.    Medicaid expansion is what we should be getting, not some block grant that will not give people healthcare!    Jo‐Ann Murphy  1790 Fraley Road  Dayton, TN 37321  71 Jonathan Reeve From: Sent: To: Subject: Vivian Ervin Tuesday, October 8, 2019 1:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Attn: Mr. Gabe Roberts, Director, Division of Tenncare NO TO GOVERNOR LEE'S BLOCK GRANT SCHEME It is time for Tennessee to accept Medicaid Expansion as law was intended and enroll the 300,000 needlessly left uninsured because of this failure. Hospital closures will continue to close if this governor/statehouse don't get their act together. This block grant scheme would totally eliminate federal standards and leave the fate of healthcare coverage for the most vulnerable at Governor Lee's discretion and healthcare coverage for all Tennesseans has never been in his game plan. Vivian Ervin 340 Pleasant Ridge Lane Lynchburg, Tennessee 37352 72 Jonathan Reeve From: Sent: To: Subject: Wilma McDonald Tuesday, October 8, 2019 12:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant???   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern, With Tennessee being one of the unhealthiest states in America and a leader in the nation in per capita hospital closings, I CANNOT support an idea such as the "Block Grant." We need the Federal Government to provide funding not in a form of a Block Grant, but in a specific amount for our TennCare (Medicaid Program). Since 2010, Tennessee has made the cruel decision to reject federal money offered in health assistance (almost a billion dollars a year) for one reason or another...Why?). One in ten Tennesseans does not have health insurance; and our children, whether they be lower income or rich, need health insurance. Several of Tennessee's hospitals in the rural areas have already closed. No other state in the nation is using this Block Grant. So...Tennessee, just say NO to...the Medicaid Block Grant!! Sincerely, Wilma McDonald 3818 West End Ave., Unit 212 Nashville, TN 37205 73 Jonathan Reeve From: Sent: To: Subject: loveheart358@everyactioncustom.com on behalf of Linsey Love Monday, October 7, 2019 11:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. Please!     I rely Tenncare and Medicaid. When I broke my wrist, I need a physical therapy, if I didn't have that I would have a hard  time moving my wrist. I also have back and leg problems. Bursitis on my back and my legs my ankles my fingers my hips  and my back. 3 disc in my back are half way out. I have  COPD, asthma. And I'm raising My Grandson.      People out here need help. We don't need a band‐aid. We need great medical care. Like you have. We care for our  families. We work hard. I worked all my life. Now I'm 61 and disabled. Please do Not go forward with this. It will hurt  more people and help none. I ask you with all my heart. Please put the People first.                     Thank you,                       Linsey Love            loveheart358@gmail.com                  615‐589‐0218    Sincerely,  Miss Linsey Love  616 Whispering Oaks Pl  Nashville, TN 37211‐1474 loveheart358@gmail.com  74 Jonathan Reeve From: Sent: To: Subject: j_k_lee@everyactioncustom.com on behalf of Janet Lee Tuesday, October 8, 2019 4:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Janet Lee  1922 Riverwood Dr  Nashville, TN 37216‐2942 j_k_lee@me.com  75 Jonathan Reeve From: Sent: To: Subject: abutler53@everyactioncustom.com on behalf of Majorie Butler Tuesday, October 8, 2019 5:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] if this succeeds, it will be a crime against humanity!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Majorie Butler  7474 Highway 52 E  Lafayette, TN 37083‐3864 abutler53@yahoo.com  76 Jonathan Reeve From: Sent: To: Subject: Kimberly Bradford Tuesday, October 8, 2019 9:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Medicaid Block Grant Public Comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern,     My name is Kimberly Bradford, I am a Tennessee constituent living in zip code 37921. I am asking legislators to vote  AGAINST allowing the state of Tennessee to convert its current Medicaid program (called TennCare) into a “block grant.”  This change would eliminate patient safeguards and federal standards around healthcare quality, and it would be  devastating to my community.     Regards,   Kimberly Bradford  37921      77 Jonathan Reeve From: Sent: To: Subject: calvinkimbrough@everyactioncustom.com on behalf of R Calvin Kimbrough Jr Monday, October 7, 2019 8:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Rev R Calvin Kimbrough Jr  1900 Acklen Ave  Nashville, TN 37212‐3728 calvinkimbrough@bellsouth.net  78 Jonathan Reeve From: Sent: To: Subject: larry.okuneff@everyactioncustom.com on behalf of Larry Okuneff Monday, October 7, 2019 8:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Larry Okuneff  2523 Sunset Pl  Nashville, TN 37212‐4813 larry.okuneff@gmail.com  79 Jonathan Reeve From: Sent: To: Subject: mbsings@everyactioncustom.com on behalf of Mary Beth Cysewski Monday, October 7, 2019 8:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mary Beth Cysewski  2615 Essex Pl  Nashville, TN 37212‐4121  mbsings@comcast.net  80 Jonathan Reeve From: Sent: To: Subject: karla.poole@everyactioncustom.com on behalf of Karla Poole Monday, October 7, 2019 8:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Karla Poole  1925 Ashland City Rd  Clarksville, TN 37043‐5201 karla.poole@icloud.com  81 Jonathan Reeve From: Sent: To: Subject: ebrrice86@everyactioncustom.com on behalf of Elizabeth Rice Monday, October 7, 2019 8:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Elizabeth Rice  3510 Golf St Apt 2 Nashville, TN 37216‐3301 ebrrice86@gmail.com  82 Jonathan Reeve From: Sent: To: Subject: janellewood27@everyactioncustom.com on behalf of Janelle Wood Monday, October 7, 2019 8:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Janelle Wood  1308 Forrest Ave  Nashville, TN 37206‐2742 janellewood27@gmail.com  83 Jonathan Reeve From: Sent: To: Subject: haleywhite106@everyactioncustom.com on behalf of Haley White Monday, October 7, 2019 8:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Haley White  3909 Elkins Ave  Nashville, TN 37209‐3719 haleywhite106@gmail.com  84 Jonathan Reeve From: Sent: To: Subject: lydiahyche@everyactioncustom.com on behalf of Lydia Hyche Monday, October 7, 2019 8:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lydia Hyche  915 Brown Dr Apt D5 Murfreesboro, TN 37130‐1862 lydiahyche@gmail.com  85 Jonathan Reeve From: Sent: To: Subject: kikikelly1982@everyactioncustom.com on behalf of Kristen Kelly Monday, October 7, 2019 8:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kristen Kelly  Cedar Hill, TN 37032  kikikelly1982@gmail.com  86 Jonathan Reeve From: Sent: To: Subject: royalpug@everyactioncustom.com on behalf of Susan Bradford Monday, October 7, 2019 8:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] The Poor in Our State are Drowning Already Block Grant Proposal   Dear Gabe Roberts,    Very few states did not expand Medicaid and unfortunately Tennessee is one of them. The system here is failing already.  As a disabled full time caregiver I cannot afford medical care for myself. In other states that did expand Medicaid, I  would be able to monitor my health and get much needed care in order to help my disabled husband and our special  needs children. Tennessee has more than its fair of the poor and the poor out here cannot get a “leg up”. If we did  expand, fewer people would be falling through the cracks. The whole “block grant” deal would only drag us down  further.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans!    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and ARBITRARILY limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. Please don’t allow Tennesseans to be discounted  and discarded in this manner.    Sincerely,  Mrs. Susan Bradford  946 Drum Ln  Clarksville, TN 37043‐8411  royalpug@yahoo.com  87 Jonathan Reeve From: Sent: To: Subject: watson.j@everyactioncustom.com on behalf of Jane Watson Monday, October 7, 2019 8:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Jane Watson  1121 Meadow Bridge Ln  Arrington, TN 37014‐9109 watson.j@comcast.net  88 Jonathan Reeve From: Sent: To: Subject: hakern@everyactioncustom.com on behalf of Heather Hicox Monday, October 7, 2019 9:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Heather Hicox  1104 Fitzpatrick Rd  Nashville, TN 37214‐3958 hakern@gmail.com  89 Jonathan Reeve From: Sent: To: Subject: samanthafrancesmusic@everyactioncustom.com on behalf of Samantha Cutler Monday, October 7, 2019 9:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Samantha Cutler  400 Avondale Dr  Nashville, TN 37206‐1819 samanthafrancesmusic@gmail.com  90 Jonathan Reeve From: Sent: To: Subject: russanne@everyactioncustom.com on behalf of Russanne Buchi-Fotre Monday, October 7, 2019 9:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid for our state   Dear Gabe Roberts,    As a Social Worker working with the Homeless and a foster family, I am opposed to the proposal to radically change  Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into a “block  grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Russanne Buchi‐Fotre  3005 Blakemore Ave  Nashville, TN 37212‐3325 russanne@comcast.net  91 Jonathan Reeve From: Sent: To: Subject: AMMaxcey@everyactioncustom.com on behalf of Ashleigh Maxcey Monday, October 7, 2019 9:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ashleigh Maxcey  Franklin, TN 37069  AMMaxcey@gmail.com  92 Jonathan Reeve From: Sent: To: Subject: meg.a.garrison@everyactioncustom.com on behalf of Megan Garrison Monday, October 7, 2019 9:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Megan Garrison  Mount Juliet, TN 37122  meg.a.garrison@gmail.com  93 Jonathan Reeve From: Sent: To: Subject: nichelekali@everyactioncustom.com on behalf of Nichele Heller Monday, October 7, 2019 10:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Nichele Heller  825 Acklen Ave  Nashville, TN 37203‐5407 nichelekali@gmail.com  94 Jonathan Reeve From: Sent: To: Subject: aef03@everyactioncustom.com on behalf of Adrienne Frey Monday, October 7, 2019 11:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Adrienne Frey  403 Stable Dr  Franklin, TN 37069‐4138  aef03@bellsouth.net  95 Jonathan Reeve From: Sent: To: Subject: olivia3579@everyactioncustom.com on behalf of Olivia Pendergrass Monday, October 7, 2019 11:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment in opposition of Medicaid Block Grants   Dear Gabe Roberts,         Please do not change Medicaid over into this block grant. I am afraid of losing my insurance benefits. I am an  underprivileged single mom and have a disabled daughter who I need to take care of. I need my healthcare and  medications myself for several medical conditions. My daughter needs many things including formula and feeding tube  supplies, therapies,  Autism support, healthcare for her eye condition which has caused Legal blindness, and help for  other health issues she has.          I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Olivia Pendergrass  1432 White Bluff Rd  White Bluff, TN 37187‐4829 olivia3579@att.net  96 Jonathan Reeve From: Sent: To: Subject: kathleen.wolff@everyactioncustom.com on behalf of kathleen wolff Monday, October 7, 2019 4:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    To Whom It May Concern,  I have been a Family Nurse Practitioner in Nashville since 1984.  I have been affiliated with both St. Thomas and  Vanderbilt Hospitals. I have had the honor and great responsibility for caring for patients whose only health care  coverage is made possible by TennCare.  I worked as a Diabetes Specialist for the first 30 years and have worked in  Integrative Medicine since then.  Many of the patients I have cared for belong to vulnerable populations.  The majority  have very complex medical and psychological conditions.  They require extensive and specialized care to prevent  hospitalizations and to help them remain or regain the ability to be a productive member of society.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.”  It is my belief that this proposal would cause immense  harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathleen Wolff, APRN, BC‐FNP    Sincerely,  Ms. kathleen wolff  5268 Old Hickory Blvd  Nashville, TN 37218‐4303 kathleen.wolff@vumc.org  97 Jonathan Reeve From: Sent: To: Subject: apriceneff@everyactioncustom.com on behalf of Amy Price Neff Monday, October 7, 2019 5:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Amy Price Neff  2808 Acklen Ave  Nashville, TN 37212‐3312 apriceneff@gmail.com  98 Jonathan Reeve From: Sent: To: Subject: nursemom703@everyactioncustom.com on behalf of Marcia Fouch Monday, October 7, 2019 5:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    As a nurse taking care of a patient onTennCare. This would be devastating to this family.  My concern is how would  TennCare pick who could stay on these benefits? It says the sickest people would stay!!  I've observed over the last few years how TennCare fights to pay for items that are very very necessary for the care of  patients and how TennCare asks medical suppliers to supply "cheaper"products and supplies. I understand that  everyone wants to save money,however its at the expense of the patient.    Sincerely,  Marcia Fouch  3023 Bryan Rd Lot 23 Kodak, TN 37764‐1553 nursemom703@yahoo.com  99 Jonathan Reeve From: Sent: To: Subject: adrolsum1@everyactioncustom.com on behalf of Aden Drolsum Monday, October 7, 2019 7:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a social work student who will work with clients who rely on TennCare to receive vital services, I am opposed to the  proposal to radically change Tennessee’s Medicaid partnership with the federal government by converting federal  funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Healthcare should not be a political issue. Every person deserves equal access to life‐saving services, and no one should  worry whether they can visit a healthcare provider when they are sick or injured.     Sincerely,  Aden Drolsum  Nashville, TN 37209  adrolsum1@gmail.com  100 Jonathan Reeve From: Sent: To: Subject: portlync@everyactioncustom.com on behalf of Portlyn Cruise Monday, October 7, 2019 7:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Portlyn Cruise  Nashville, TN 37216  portlync@gmail.com  101 Jonathan Reeve From: Sent: To: Subject: sherizna@everyactioncustom.com on behalf of Cherisna Jean-Marie Monday, October 7, 2019 7:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Cherisna Jean‐Marie  1027 18th Ave S  Nashville, TN 37212‐2104 sherizna@hotmail.com  102 Jonathan Reeve From: Sent: To: Subject: jessicalynn.rosen@everyactioncustom.com on behalf of Jessica Rosen Monday, October 7, 2019 7:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As an emergency physician who cares for many TNCare patients, I am opposed to the proposal to radically change  Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into a “block  grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr Jessica Rosen  Nashville, TN 37209  jessicalynn.rosen@gmail.com  103 Jonathan Reeve From: Sent: To: Subject: jeni.landau@everyactioncustom.com on behalf of Jeni Miller Monday, October 7, 2019 7:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    As a nurse manager in middle Tennessee, the risk of losing safeguards for patients is incredibly important to me. Many  of my patients and community members rely on TennCare.  Please protect the rights of our fellow Tennesseans.     Sincerely,  Jeni Miller  Nashville, TN 37208  jeni.landau@gmail.com  104 Jonathan Reeve From: Sent: To: Subject: llwalls3043@everyactioncustom.com on behalf of Lisa Walls Monday, October 7, 2019 7:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. Yours truly:  Lisa Walls  915 West Spring Street   Lebanon, TN 37087    Sincerely,  Ms. Lisa Walls  915 W Spring St  Lebanon, TN 37087‐3337  llwalls3043@yahoo.com  105 Jonathan Reeve From: Sent: To: Subject: queengancy@everyactioncustom.com on behalf of Nancy Goff Monday, October 7, 2019 7:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Nancy Goff  Gainesboro, TN 38562  queengancy@gmail.com  1 Jonathan Reeve From: Sent: To: Subject: armstroca@everyactioncustom.com on behalf of Caitlyn Armstrong Monday, October 7, 2019 7:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Caitlyn Armstrong  1027 Rucker Ln  Murfreesboro, TN 37128‐5012 armstroca@gmail.com  2 Jonathan Reeve From: Sent: To: Subject: myra.davis5@everyactioncustom.com on behalf of myra Davis Monday, October 7, 2019 7:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss myra Davis  4467 Webb Ln  Murfreesboro, TN 37129‐7638 myra.davis5@me.com  3 Jonathan Reeve From: Sent: To: Subject: 12wilsonk@everyactioncustom.com on behalf of Kaitlyn Wilson-Periola <12wilsonk@everyactioncustom.com> Monday, October 7, 2019 7:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Kaitlyn Wilson‐Periola  200 S Hampton Pl  Clarksville, TN 37040‐6359 12wilsonk@gmail.com  4 Jonathan Reeve From: Sent: To: Subject: paula16012@everyactioncustom.com on behalf of Paula Simmons Monday, October 7, 2019 7:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Paula Simmons  949 Old Gainesboro Hwy  Cookeville, TN 38501‐8996 paula16012@yahoo.com  5 Jonathan Reeve From: Sent: To: Subject: samantha.grace.rich@everyactioncustom.com on behalf of Samantha Rich Monday, October 7, 2019 7:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Samantha Rich  504 Castle Heights Ave  Lebanon, TN 37087‐3818 samantha.grace.rich@hotmail.com  6 Jonathan Reeve From: Sent: To: Subject: saimuraiclayton@everyactioncustom.com on behalf of Sai Clayton Monday, October 7, 2019 7:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sai Clayton  Nashville, TN 37209  saimuraiclayton@gmail.com  7 Jonathan Reeve From: Sent: To: Subject: swalton007@everyactioncustom.com on behalf of Sarah Walton Monday, October 7, 2019 7:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sarah Walton  100 S 14th St  Nashville, TN 37206‐2839  swalton007@gmail.com  8 Jonathan Reeve From: Sent: To: Subject: mimijay418@everyactioncustom.com on behalf of Mimi Brown Monday, October 7, 2019 7:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mimi Brown  3600 Hillsboro Pike  Nashville, TN 37215‐2100 mimijay418@gmail.com  9 Jonathan Reeve From: Sent: To: Subject: catgoddess3@everyactioncustom.com on behalf of Laura Jordan Monday, October 7, 2019 7:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Laura Jordan  2645 Highway 76  Portland, TN 37148‐6016 catgoddess3@gmail.com  10 Jonathan Reeve From: Sent: To: Subject: kristenruthsmith@everyactioncustom.com on behalf of Kristen Ruth Smith Monday, October 7, 2019 7:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kristen Ruth Smith  5506 Tennessee Ave  Nashville, TN 37209‐2042 kristenruthsmith@icloud.com  11 Jonathan Reeve From: Sent: To: Subject: youcanemaildon@everyactioncustom.com on behalf of Donald Plunk Monday, October 7, 2019 7:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Donald Plunk  2907 Mavert Dr  Nashville, TN 37211‐2703 youcanemaildon@yahoo.com  12 Jonathan Reeve From: Sent: To: Subject: larabrothers@everyactioncustom.com on behalf of Lara Brothers Monday, October 7, 2019 7:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lara Brothers  4415 Pecan Valley Rd  Nashville, TN 37218‐4214 larabrothers@gmail.com  13 Jonathan Reeve From: Sent: To: Subject: queengancy@everyactioncustom.com on behalf of Nancy Goff Monday, October 7, 2019 7:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Nancy Goff  Gainesboro, TN 38562  queengancy@gmail.com  14 Jonathan Reeve From: Sent: To: Subject: rtanay@everyactioncustom.com on behalf of Ryan Tanay Monday, October 7, 2019 7:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] No Block Grant for Medicaid   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Tennessee should be known as a healthcare innovator and this proposal flies in the face of that.     Sincerely,  Ryan Tanay  2727 Tower Dr  Murfreesboro, TN 37129‐1177 rtanay@gmail.com  15 Jonathan Reeve From: Sent: To: Subject: amandalee.matsui@everyactioncustom.com on behalf of Amanda Matsui Monday, October 7, 2019 7:16 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amanda Matsui  1720 Ordway Pl  Nashville, TN 37206‐1834 amandalee.matsui@gmail.com  16 Jonathan Reeve From: Sent: To: Subject: delightr58@everyactioncustom.com on behalf of Richard Delight Monday, October 7, 2019 7:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr Richard Delight  155 Ballard Ln  Cookeville, TN 38501‐9573 delightr58@gmail.com  17 Jonathan Reeve From: Sent: To: Subject: agbaird1@everyactioncustom.com on behalf of Kelly Baird Monday, October 7, 2019 7:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Kelly Baird  311 Birkshire Pl  Gallatin, TN 37066‐6746 agbaird1@aol.com  18 Jonathan Reeve From: Sent: To: Subject: hhender@everyactioncustom.com on behalf of Heather Henderson Monday, October 7, 2019 7:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Heather Henderson  126 A Kingston St  Nashville, TN 37207‐4546 hhender@gmail.com  19 Jonathan Reeve From: Sent: To: Subject: georgiad6@everyactioncustom.com on behalf of Georgia Deffner Monday, October 7, 2019 7:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Georgia Deffner  1527 Ferguson Ave  Nashville, TN 37212‐6111 georgiad6@gmail.com  20 Jonathan Reeve From: Sent: To: Subject: ashtonwhite2018@everyactioncustom.com on behalf of Ashton White Monday, October 7, 2019 7:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ashton White  Old Hickory, TN 37138  ashtonwhite2018@gmail.com  21 Jonathan Reeve From: Sent: To: Subject: earlredmond@everyactioncustom.com on behalf of Earl Redmond Monday, October 7, 2019 7:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Earl Redmond  5208 W Calgary  Murfreesboro, TN 37129‐8063 earlredmond@bellsouth.net  22 Jonathan Reeve From: Sent: To: Subject: arosenberger@everyactioncustom.com on behalf of Amanda Rosenberger Monday, October 7, 2019 7:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Amanda Rosenberger  235 N Dixie Ave  Cookeville, TN 38501‐3325 arosenberger@tntech.edu  23 Jonathan Reeve From: Sent: To: Subject: hannahjones1013@everyactioncustom.com on behalf of Hannah jones Monday, October 7, 2019 7:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Hannah jones  Nashville, TN 37211  hannahjones1013@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: andrew.geisler@everyactioncustom.com on behalf of Andrew Geisler Monday, October 7, 2019 7:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Andrew Geisler  Old Hickory, TN 37138  andrew.geisler@gmail.com  25 Jonathan Reeve From: Sent: To: Subject: cjeancole@everyactioncustom.com on behalf of Ciandra Cole Monday, October 7, 2019 7:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ciandra Cole  2009 Shaylin Loop  Antioch, TN 37013‐8406 cjeancole@gmail.com  26 Jonathan Reeve From: Sent: To: Subject: alainarhiann@everyactioncustom.com on behalf of Alaina Solis Monday, October 7, 2019 7:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    As a college student, I often struggle with money and I rely on TennCare when I need any medical attention. I implore  you to reconsider.    Sincerely,  Alaina Solis  1641 Benton Young Rd Apt 2 Cookeville, TN 38501‐0767 alainarhiann@gmail.com  27 Jonathan Reeve From: Sent: To: Subject: h_e_b@everyactioncustom.com on behalf of Hannah Barger Monday, October 7, 2019 7:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Hannah Barger  Lebanon, TN 37090  h_e_b@aol.com  28 Jonathan Reeve From: Sent: To: Subject: staufferkm@everyactioncustom.com on behalf of Kim Alexander Monday, October 7, 2019 7:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kim Alexander  400 School Pass  Madison, TN 37115‐5445  staufferkm@gmail.com  29 Jonathan Reeve From: Sent: To: Subject: donowen33@everyactioncustom.com on behalf of DON OWEN Monday, October 7, 2019 7:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal is a huge mistake   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. DON OWEN  198 Mcniel Dr  Murfreesboro, TN 37128‐4504 donowen33@gmail.com  30 Jonathan Reeve From: Sent: To: Subject: lisetrigger@everyactioncustom.com on behalf of Lise Triggs Monday, October 7, 2019 7:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lise Triggs  1120 Hunting Creek Rd  Franklin, TN 37069‐4754 lisetrigger@comcast.net  31 Jonathan Reeve From: Sent: To: Subject: jm.mildenberger@everyactioncustom.com on behalf of Jean Mildenberger Monday, October 7, 2019 7:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jean Mildenberger  2805 Kaye Dr  Thompsons Station, TN 37179‐5046 jm.mildenberger@gmail.com  32 Jonathan Reeve From: Sent: To: Subject: b.hippie@everyactioncustom.com on behalf of Betsi Tunnell Monday, October 7, 2019 7:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Betsi Tunnell  6868 River Ridge Dr  Nashville, TN 37221‐3379 b.hippie@comcast.net  33 Jonathan Reeve From: Sent: To: Subject: drchristinemayer1@everyactioncustom.com on behalf of Christine Mayer Monday, October 7, 2019 7:35 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr Christine Mayer  2810 Colonial Cir  Nashville, TN 37214‐2908 drchristinemayer1@gmail.com  34 Jonathan Reeve From: Sent: To: Subject: ladydragynslair@everyactioncustom.com on behalf of Elizabeth Burch Monday, October 7, 2019 7:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Elizabeth Burch  716 Vauxhall Dr  Nashville, TN 37221‐4646 ladydragynslair@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: acw230@everyactioncustom.com on behalf of Ashley Walker Monday, October 7, 2019 7:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ashley Walker  116 Inverness Dr  Burns, TN 37029‐5687  acw230@gmail.com  36 Jonathan Reeve From: Sent: To: Subject: lailahsartwork@everyactioncustom.com on behalf of Lailah Abonami Monday, October 7, 2019 7:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.”    I am currently expecting my first child and rely on Tenncare  to get the  prenatal care I need.  My husband and I are both  self‐employed  and the only other option for us would be to get private insurance which cost more than our mortgage.  We don’t plan on being recipients of Tenncare for long but during this time  in our lives it is the only way we can afford  to have a healthy pregnancy and birth of our son without going into financial ruin.     Tenncare is so vitally important for us and many others.  Without it we would not be able to start our family.  We are so  grateful for Tenncare. Please protect Tennessee’s Medicaid program  so that other families can find hope in their time of  medical need.     Sincerely,  Lailah Abonami  Nashville, TN 37206  lailahsartwork@gmail.com  37 Jonathan Reeve From: Sent: To: Subject: sbyankeesgirl@everyactioncustom.com on behalf of Stacy Jones Butterworth Monday, October 7, 2019 7:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Stacy Jones Butterworth  1418 Knox Valley Dr  Brentwood, TN 37027‐7122 sbyankeesgirl@gmail.com  38 Jonathan Reeve From: Sent: To: Subject: sareed307@everyactioncustom.com on behalf of Ash Reed Monday, October 7, 2019 7:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ash Reed  4352 Cambridge Dr  Antioch, TN 37013‐1131 sareed307@yahoo.com  39 Jonathan Reeve From: Sent: To: Subject: rwspry@everyactioncustom.com on behalf of Richard Spry Monday, October 7, 2019 7:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposed change to Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     We have wonderful neighbors, a family of seven. They depend on TennCare. They are hardworking, caring people, who  are wonderful members of our community. The need our help through TennCare.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Richard Spry  2414 Spaulding Cir  Murfreesboro, TN 37128‐4823 rwspry@gmail.com  40 Jonathan Reeve From: Sent: To: Subject: kbarnetttn@everyactioncustom.com on behalf of Kirsten Barnett Monday, October 7, 2019 7:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kirsten Barnett  1608 Bailey Ave  Chattanooga, TN 37404‐3001 kbarnetttn@gmail.com  41 Jonathan Reeve From: Sent: To: Subject: peggy.okuneff@everyactioncustom.com on behalf of Peggy Okuneff Monday, October 7, 2019 7:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Peggy Okuneff  2523 Sunset Pl  Nashville, TN 37212‐4813 peggy.okuneff@gmail.com  42 Jonathan Reeve From: Sent: To: Subject: lusf33@everyactioncustom.com on behalf of Lou Demarco Monday, October 7, 2019 7:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. Come on, let’s do the right thing in Tennessee.    Sincerely,  Mr. Lou Demarco  1519 Russell St  Nashville, TN 37206‐2043 lusf33@gmail.com  43 Jonathan Reeve From: Sent: To: Subject: lahammett@everyactioncustom.com on behalf of Leisa Hammett Monday, October 7, 2019 1:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I waited for a dozen years for my daughter with autism and my family to receive state help with her disability. Thank you  for ECF CHOICES waiver‐program. However, the rolls, three years in, are already closed for more enrollment. I worry that  more families will be without services when their loved ones reach the crucial transition age out of school. Our state will  pay more for in‐patient care because that's what happens when these vulnerable people are suddenly left with no  services. Accepting a block grant will limit more people gaining assistance.         Sincerely,  Leisa Hammett  223 Windsor Terrace Dr  Nashville, TN 37221‐2277 lahammett@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: ptbrown50@everyactioncustom.com on behalf of Patsy Brown Monday, October 7, 2019 2:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,   Patsy T. Brown  Memphis, TN 38116    Sincerely,  Patsy Brown  702 Brownlee Rd  Memphis, TN 38116‐6204  ptbrown50@yahoo.com  45 Jonathan Reeve From: Sent: To: Subject: deborah.cogswell@everyactioncustom.com on behalf of Deborah Cogswell Monday, October 7, 2019 2:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Maternal Child Registered Nurse Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a Masters prepared Registered nurse with 40+ years spent in the Maternal Child field, caring for mothers, families  and children.  I also have served for 10 years on the Davidson County Fetal and Infant Mortality Review Board in which we review  cases of fetal, infant, and child death to determine if our public programs and support services were adequate and what  might have been done further to prevent these losses. It is evident in reviewing these cases how important TennCare  access is to the prenatal and obstetric health of these patients and how maternal health affects the health of the infant.  If you care about life, the preservation and quality of each person's life, then I ask that Medicaid funding be protected  and expanded.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Deborah Cogswell MSN, RN  1416 Eastland Avenue  Nashville, TN 37206    Sincerely,  Mrs. Deborah Cogswell  1416 Eastland Ave  Nashville, TN 37206‐2627 deborah.cogswell@gmail.com  46 Jonathan Reeve From: Sent: To: Subject: beebeeschnuffel1@everyactioncustom.com on behalf of Debora Ramos Ramos Monday, October 7, 2019 3:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     1. With this proposal being the first of its kind, you would expect a sensible study conducted in determining how this will  affect the citizens of TN. How will this affect an aging population, adults and children with disabilities, low income  parents? More than anything the verbiage of the proposal emphasizes one thing and one thing only, monetary cuts.  How does the state plan on cutting costs and improving the health of children in the state!? Tennessee suffers some of  the highest uninsured rates in the country. Highest rates of hospital closures, infant mortality rates, mother mortality  rates. If the goal is to cut costs and be fiscally conservative, where is the proof that the health of Tennesseans will  improve?  2. Has the state fixed the problems that resulted in the mass unenrollment of 200,000 children from Tenncare? The  outdated 98 page application forms with dubious questions that must be sent in through fax or snail mail. Wrong  addresses, unprocessed applications despite receiving them?   3. The only exemption to cuts is administrative costs. This needs to be thoroughly explained because it seems like we're  making sure that someones salary is being protected versus the health of Tennesseans.   4. Relying on the CBO projections to estimate the cost of the program is concerning. CBO projections require revisions.  Inflation rates variate and this is how the grant amounts will be determined.  5. Further hurting children, low income parents, senior citizens and the disabled, the state will be ending it's  commitment to the costs of improving the health of its own citizens.  6. Risking the health of senior citizens, disabled adults and children to champion fiscal conservatism when there is  federal money available is morally reprehensible.   As a mother of an autistic child, I take his health and well being very seriously. My responsibility to my child is of the  utmost importance to me and I advocate for him at all times. The Tenncare program has been incredibly helpful to my  child. To think that that help could be in jeopardy because of political ideology is disheartening. As I mentioned before,  Tennessee has a long way to go when it comes to the health of its citizens and this block grant proposal will do nothing  to make improvements. We need to accept the Medicaid money that is available now. Improve Tenncare don't destroy  it. My child depends on it.    Sincerely,  Debora Ramos Ramos  170 Hoover Dr  Mcminnville, TN 37110‐4184 beebeeschnuffel1@gmail.com  47 Jonathan Reeve From: Sent: To: Subject: kchiles1@everyactioncustom.com on behalf of Katy Chiles Monday, October 7, 2019 9:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Katy Chiles  2105 Buckingham Cir  Maryville, TN 37803‐6504 kchiles1@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: su2pan@everyactioncustom.com on behalf of susan pankowsky Monday, October 7, 2019 10:09 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. susan pankowsky  PO Box 50186  Nashville, TN 37205‐0186  su2pan@yahoo.com  49 Jonathan Reeve From: Sent: To: Subject: Ellarudd1@everyactioncustom.com on behalf of Ella Rudd Monday, October 7, 2019 10:38 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Ella Rudd  7864 Parkmont Dr  Memphis, TN 38125‐4830 Ellarudd1@comcast.net  50 Jonathan Reeve From: Sent: To: Subject: Richard9865@everyactioncustom.com on behalf of Tammy Molder Monday, October 7, 2019 10:40 AM PUBLICE NOTICE TENNCARE [EXTERNAL] This is another example of why we have a health care crises in America and why we need to put humanity above corporate greed!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Tammy Molder  800 Mapleview Dr  Shelbyville, TN 37160‐7368 Richard9865@att.net  51 Jonathan Reeve From: Sent: To: Subject: mfugate@everyactioncustom.com on behalf of Mary Fugate Monday, October 7, 2019 10:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mary Fugate  308 Kingview Dr  Nashville, TN 37218‐1933 mfugate@fcsnashville.org  52 Jonathan Reeve From: Sent: To: Subject: cruzecon@everyactioncustom.com on behalf of Ethan Cruze Sunday, October 6, 2019 12:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It may also be in conflict with a provision in the overriding  Federal law. It goes against the goals and purpose of the Medicaid program. We respectfully urge you not to go forward  with this harmful proposal.    Sincerely,  Mr. Ethan Cruze  6186 Highway 11W S  Bean Station, TN 37708‐6031 cruzecon@aol.com  53 Jonathan Reeve From: Sent: To: Subject: elfab418@everyactioncustom.com on behalf of Ellen Faby Sunday, October 6, 2019 12:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I strongly oppose the proposal to convert federal funding for TennCare into a block grant program.  This would be  harmful, not only to the people who rely on TennCare so that they can receive life‐saving healthcare, but it would also  harm our state by further eroding our healthcare system of providers and hospitals, thus making it less attractive for  employers to bring new jobs to our state. This proposal is a radical change to Tennessee’s Medicaid partnership with the  federal government and it would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     I pay federal taxes and I want my federal taxes to be used to help less fortunate Tennesseans.  Improved health and  welfare for our citizens benefit all of us because our economy improves and employers find Tennessee a good place to  create jobs. A block grant program would have an overall detrimental effect on the health and welfare of Tennessee's  citizens and economy.    I am fortunate to be able to purchase subsidized health insurance. But I know many people rely on TennCare, like my  friend John who relies on help from TennCare to pay his Medicare premiums, deductibles, and co‐pays; without  TennCare, these payments would be difficult for him due to his low social security benefits. Many vulnerable  Tennesseans like John would be negatively impacted by changes to TennCare that would eliminate federal  accountability and standards and patient protections.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ellen Faby  418 Orchard Knob Rd  Clinton, TN 37716‐7905 elfab418@gmail.com  54 Jonathan Reeve From: Sent: To: Subject: teenaaray@everyactioncustom.com on behalf of Teena Ray Sunday, October 6, 2019 12:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am on Medicare now, but I know what it is like to be uninsured and in poor health. Fortunately  I had parents who were  willing and able to help me when I was younger.     Many of my major life choices were made based on my health and the need for medical insurance. Good medical care  has allowed me to live in reasonable health long enough to qualify for Medicare and to be a productive and contributing  citizen along the way.     Other Tennessee citizens need and deserve the same opportunities.    I know our new governor feels the need to do something on this issue without alienating the party that elected him. But  this block grant is the wrong choice.    Kentucky made the right choice and it has greatly benefited their state. Shouldn't we be as smart as Kentucky, and many  other states who have expanded the Affordable Care Act? Do we really need to seem like ignorant hillbillies to the rest  of the country, just for the sake of partisan politics??    The Affordable Care Act is not perfect but it is tried and proven effective in the majority of states. Let's go with tried and  proven. We can't afford to reinvent the wheel when Tennessee lives are at stake. Numerous hospital closings in our  state hurt not only medical needs but damage local economies as well.    I go on record as being opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” I respectfully urge you not to go forward  with this harmful proposal.    Sincerely,  Teena Ray  728 Bacon Trl Apt 56 Chattanooga, TN 37412‐2155 teenaaray@aol.com  55 Jonathan Reeve From: Sent: To: Subject: gallionfre@everyactioncustom.com on behalf of Freddie Gallion Sunday, October 6, 2019 9:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Freddie Gallion  Dickson, TN 37055  gallionfre@yahoo.com  56 Jonathan Reeve From: Sent: To: Subject: saveourearth@everyactioncustom.com on behalf of Kimberly Davis Sunday, October 6, 2019 11:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kimberly Davis  Knoxville, TN 37917  saveourearth@fredsgarage.net  57 Jonathan Reeve From: Sent: To: Subject: dayleelou@everyactioncustom.com on behalf of Dayle Morse Sunday, October 6, 2019 11:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    It sounds like there's going to still be people needing help and no funds available by the end of the year. People,will not  go to,their Dr when necessary to keep from spending to much. And be going without needed medicine for the same  reason. Not a good idea.   Why don't you try living like that. Try living on the amount ssa had ssi get. They won't be able to afford the extra  expense themselves.    Sincerely,  Ms Dayle Morse  3375  Puryear, TN 38251  dayleelou@gmail.com  58 Jonathan Reeve From: Sent: To: Subject: fhollowell@everyactioncustom.com on behalf of Faye Hollowell Sunday, October 6, 2019 12:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Faye Hollowell  Cordova, TN 38016  fhollowell@comcast.net  59 Jonathan Reeve From: Sent: To: Subject: bradh_42@everyactioncustom.com on behalf of Brad Hoot Saturday, October 5, 2019 8:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I want to clearly state that I oppose the Medicaid Block Grant Proposal because that is just not the right choice to  protect the hard‐working Tennesseans who need healthcare and just can't afford it.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Brad Hoot  105 Lakeshire Dr  Crossville, TN 38558‐9005 bradh_42@bellsouth.net  60 Jonathan Reeve From: Sent: To: Subject: mpriestley0150@everyactioncustom.com on behalf of Mary Priestley Saturday, October 5, 2019 8:34 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms.mary Mary Priestley  215 Proctors Hall Rd  Sewanee, TN 37375‐2072 mpriestley0150@gmail.com  61 Jonathan Reeve From: Sent: To: Subject: extemporaneously@everyactioncustom.com on behalf of Jose Davila Saturday, October 5, 2019 9:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.     Some days ago, Representative Steve Cohen wrote in these pages against the proposed amendment to replace the  current Tenncare (Medicaid in Tennessee) funding scheme with a block grant.  He did not mention, however, that this  proposal makes evident that Governor Bill Lee does not care about the seven percent of Tennesseans who cannot afford  health insurance.  The block grant is presented as an innovative alternative that will add flexibility to health care  spending.  But flexibility will not provide health care to the 300,000 Tennesseans would qualify for health care under the  expansion.  And innovation will not recoup the $3.8 million that our state loses every day because it has not expanded  Medicaid.  Governor Lee should stop the block grant distraction and begin work on expanding Medicaid.       Sincerely,  Mr Jose Davila  Memphis, TN 38114  extemporaneously@hotmail.com  62 Jonathan Reeve From: Sent: To: Subject: extemporaneously@everyactioncustom.com on behalf of Jose Davila Saturday, October 5, 2019 9:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.     Some days ago, Representative Steve Cohen wrote in these pages against the proposed amendment to replace the  current Tenncare (Medicaid in Tennessee) funding scheme with a block grant.  He did not mention, however, that this  proposal makes evident that Governor Bill Lee does not care about the seven percent of Tennesseans who cannot afford  health insurance.  The block grant is presented as an innovative alternative that will add flexibility to health care  spending.  But flexibility will not provide health care to the 300,000 Tennesseans would qualify for health care under the  expansion.  And innovation will not recoup the $3.8 million that our state loses every day because it has not expanded  Medicaid.  Governor Lee should stop the block grant distraction and begin work on expanding Medicaid.         Sincerely,  Mr Jose Davila  Memphis, TN 38114  extemporaneously@hotmail.com  63 Jonathan Reeve From: Sent: To: Subject: janabell3@everyactioncustom.com on behalf of Janice Harris Saturday, October 5, 2019 4:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    I have an adult daughter who receives services through the Medicaid waiver as well as TNCare. Not only she, but  everyone at her center who badly need services will be affected by such a sham. To turn Medicaid into a block grant is  ludicrous, when this state opposed opting into the federal program a few years ago and lost so much.   I have many people I work with in service, who rely on TNCare, and this merely works to limit and deny services to the  most vulnerable of our population.       Sincerely,  Janice Harris  7608 Candies Creek Ridge Rd NW  Charleston, TN 37310‐5153 janabell3@gmail.com  64 Jonathan Reeve From: Sent: To: Subject: foxfyreutk@everyactioncustom.com on behalf of Marlene Clausen Saturday, October 5, 2019 6:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    All citizens, no matter what state they live in, should be entitled to the same care. No state should have the right to  determine who gets how much health care. Medicaid is designed to protect the health care a vulnerable population  receives. No one should suffer for lack of adequate drugs, needed procedures, or on‐going medical care because they  cannot pay for it or do not have private insurance to cover it. No state should have the right to make those choices for  anyone. Tennessee defintiely cannot be trusted to make these kinds of critical decisions. It has already shown that it  cares nothing for the health and well‐being of its most vulnerable citizens by refusing to participated in Medicaid  Expansion under the Affordable Care Act. The state should not be allowed to continue to wage it's war on the most  vulnerable of its citizens by decimating the provisions of Medicaid.    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Marlene Clausen  2012 Anderson Ave  Chattanooga, TN 37404‐4411 foxfyreutk@gmail.com  65 Jonathan Reeve From: Sent: To: Subject: mdforry@everyactioncustom.com on behalf of Dianne Forry Saturday, October 5, 2019 6:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Dianne Forry  638 Deaderick Rd  Knoxville, TN 37920‐8214 mdforry@gmail.com  66 Jonathan Reeve From: Sent: To: Subject: helise@everyactioncustom.com on behalf of Hannah Raines Saturday, October 5, 2019 7:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I Strongly Oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Hannah Raines  217 E Baxter Ave  Knoxville, TN 37917‐6437 helise@live.com  67 Jonathan Reeve From: Sent: To: Subject: pat.money51@everyactioncustom.com on behalf of Patricia Money Saturday, October 5, 2019 2:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the block grant.   Dear Gabe Roberts,    I am opposed to the proposal to radicallychange Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal. I don't trust the people that will be in charge of  making those decisions for the patients.    Sincerely,  Mrs. Patricia Money  2065 Detroit Rd  Burlison, TN 38015‐6501 pat.money51@gmail.com  68 Jonathan Reeve From: Sent: To: Subject: jlight523@everyactioncustom.com on behalf of Jeff Light Saturday, October 5, 2019 3:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jeff Light  834 Rose Park Dr  Nashville, TN 37206‐1045 jlight523@comcast.net  69 Jonathan Reeve From: Sent: To: Subject: winniekayak@everyactioncustom.com on behalf of Winnie Okumura Saturday, October 5, 2019 10:58 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Changing TennCare to block grant will place many vulnerable people in harms way   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Winnie Okumura  503 Kahite Trl  Vonore, TN 37885‐2736  winniekayak@aol.com  70 Jonathan Reeve From: Sent: To: Subject: jkzammit@everyactioncustom.com on behalf of Jessica Zammit Saturday, October 5, 2019 10:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    This is a vote in opposition to changing Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.”  Research indicates that the block grant option would cause  tremendous harm to, and jeopardize coverage for, vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely, J.K. Zammit    Sincerely,  Mrs. Jessica Zammit  1035 Laurel Branch Trl  Sewanee, TN 37375‐2862 jkzammit@yahoo.com  71 Jonathan Reeve From: Sent: To: Subject: calabash52@everyactioncustom.com on behalf of Bill Freeman Saturday, October 5, 2019 11:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Bill Freeman  600 Athens Pike  Etowah, TN 37331‐1706  calabash52@gmail.com  72 Jonathan Reeve From: Sent: To: Subject: scott.conder@everyactioncustom.com on behalf of Scott Conder Saturday, October 5, 2019 11:42 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for vulnerable Tennesseans.     It is in no way an improvement and it evades the serious problems facing Tennesseans. It makes the government (state  and federal) the entire focus and ignores the real people with real and undeserved health problems. To me, that sounds  like government of, by, and for the few elite who control it.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Scott Conder  315 Margo Ln  Nashville, TN 37211‐5572  scott.conder@att.net  73 Jonathan Reeve From: Sent: To: Subject: brandtp@everyactioncustom.com on behalf of Patricia Brandt Saturday, October 5, 2019 11:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Patricia Brandt  160 Mirror Lk  Dunlap, TN 37327‐6782  brandtp@bledsoe.net  74 Jonathan Reeve From: Sent: To: Subject: indaspring@everyactioncustom.com on behalf of John reis Saturday, October 5, 2019 11:49 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal program. I  respectfully urge you not to go forward with this harmful proposal. This is a typical Republican idea that looks  reasonable on its surface but is designed to cut benefits for the neediest people in our society. This is classic Paul Ryan  Republicanism. Bend over backwards to make things easy for the wealthy while telling poor people to pull themselves  up by their bootstraps.     Sincerely,  Mr. John reis  200 Manufacturers Rd  Chattanooga, TN 37405‐3338 indaspring@yahoo.com  75 Jonathan Reeve From: Sent: To: Subject: Kevin Hood Monday, October 7, 2019 3:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] block grant comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   In regards to the block grant proposal:    Any savings realized should be put toward health education programs, Not performance bonuses for administrators. No  bonuses should be paid to administrators. This needs to be written into the proposal.  Why eliminate pharmacy costs from block grant?   What happens if costs go over block grant amount? Will services cease?  Page 14 one drug per therapeutic class my daughter takes 3 seizure meds  “ Adopting this strategy would allow the state to negotiate more favorable rebate agreements with manufacturers, since—for each therapeutic class— the state could offer manufacturers an essentially guaranteed volume in exchange for a larger rebate,”  this puts money over healthcare   While there are some good points made there are more negative ones made and more problems created. As proposed I  am against this.    Kevin Hood  Media Center  Martin Methodist College  khood@martinmethodist.edu  931‐424‐7351 office  931‐309‐2439 cell    76 Jonathan Reeve From: Sent: To: Subject: Dianna McCullough Monday, October 7, 2019 2:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To whom it may concern:    Attempting to use Block Grants in Florida to replace traditional Medicaid, here is what I learned:    a)  Block Grants cap the amount needed for individuals.  b)  Block Grants have no oversight from the Federal Government.  Allowing states to discriminate.  c) Block Grants have no guarantee an can cut or limit optimal benefits.   d) individuals and families will be at risk.    Florida did not pursue the Block Grant after it was known healthcare would be limited and create hardship for  individuals and families..    Tennessee already is in a situation of eliminating far too many children and people with disabilities off TennCare and  because they refused to take the Medicaid Expansion offer, many others have been left out.    Tennessee must not be enabled to divert funds from the healthcare system in order to spend it how they choose.  The  answer to Tennessee's healthcare needs is not to take money away, which a Block Grant would do, but to find real  answers to help those in need of healthcare.    Tennessee can do better than try to go by the way of a Block Grant.  I say please do not consider such harm to the  people.    Sincerely,  Dianna McCullough  210 McGhee Street  G7 Maryville Towers  Maryville, TN  37801  77 Jonathan Reeve From: Sent: To: Subject: Rhonda Cowden Monday, October 7, 2019 11:28 AM PUBLICE NOTICE TENNCARE [EXTERNAL] RE: Public Comment Block Grant Funding - Medicaid Program   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Gabe Roberts,             Director, Division of TennCare    I am contacting you today to submit public comment on the subject of Tennessee's proposal for a new block  grant funding program for the state's Medicaid program by Governor Bill Lee. I have read the feedback from  the public. I have viewed the debate on news sources. I have followed this subject with Governor Haslam. I am  a consumer of healthcare at many levels. I am familiar with health care with insured, uninsured, children and  without children. I have spoken with many people on this subject over a long period of time.    The Pros of Tennessee        Tennessee has some of the nations best resources in our state. We have John Hopkins, UT Medical  Center, ParkWest Hospital, Mayo Clinic coming.   Tennessee has The University of Tennessee with the Super Computer for the students to research.  Tennessee has Oak Ridge National Laboratories (ORNL).  Knoxville has a updated Megee‐Tyson Airport  Tennessee tourism is comparable to most states.  Tennessee industry is expanding with our educational system.    The Cons of Tennessee          Tennessee is closing our hospitals.  Tennessee is loosing our great doctors, nurses and medical staff.  Tennessee needs to be more competitive in medical wages/reimbursement some say.  Tennessee's current healthcare program does no longer fit the needs for the State of Tennessee, we  need updated.  A poor health care system is a deterrent for a relocating business to a state looking to bring in a large  amount of employees with no local hospitals. (liability)  Tennessee opioid epidemic is out of control.  Tennessee jails, correctional facilities and prisons are overpopulated.  Tennessee court systems are busting at the seams.   If we compare the Pros and Cons, consider the entire picture of the federal block grant proposal by Governor  Bill Lee, I believe that the the evidence speaks for its self as I see it.  I support the Medicaid federal block  proposal.  With healthcare one size does not fit all, Tennessee has special needs focusing on opioid epidemic  and rehabilitation, respiratory and cardiac for our population for example, while Florida will need long term  78 care, physical and therapy as well as skin cancer focus for their population. That is why I feel these block  grants will be effective based upon each states populations primary needs and specialty areas.    Please take my comments into consideration when making your decision.    Yours Truly,  Rhonda Cowden  1624 Sundrop Dr.  Knoxville, TN 37921  865‐654‐7336          79 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of Corinne Rovetti Monday, October 7, 2019 11:23 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    It is time that Tennessee steps up to the plate and does the right thing for all Tennesseans.  States that have expanded Medicaid have shown vast improvements of health outcomes for it's citizens. While we still  have insurance tied to employment and while we still have employers working people just below FT so to deny workers  health insurance coverage, we need to expand Medicaid so that all Tennesseans have access to healthcare.    Block Grants for Tenncare are not only illegal, they are a poor and unacceptable excuse for healthcare provision.  NO to the Governor's poor attempt at addressing the dire healthcare needs of Tennesseans.    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Corinne Rovetti  6925 Sevierville Pk  Knoxville, TN 37920‐6527   80 Jonathan Reeve From: Sent: To: Cc: Subject: Frank Zingheim Monday, October 7, 2019 11:16 AM PUBLICE NOTICE TENNCARE Jeff Fladen [EXTERNAL] Vote to veto the Block Grant being considered   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Sirs:  If you are enrolled in TennCare, you receive services through a health plan. Right now, federal regulations protect your ability access to services, ensure that plans have enough mental health professionals, and give you the ability to appeal denials of services. This block grant proposal would REMOVE these protections and open the way for health plans to cut payments to providers -- making it more difficult for you to get services and report that to anyone.  The state’s proposal would limit access to prescription drugs for beneficiaries who need them by excluding high-cost drugs from coverage. This would shift the cost of these drugs onto the beneficiaries who need them but cannot afford to pay for them.  The proposal would also limit drugs to one medication per "therapeutic class" or type. This is a problem for individuals with mental illness who sometimes need to try multiple medications before they find one that works with minimal side effects.  The state’s proposal would no longer require Tennessee to follow the federal government's list of optional and mandatory services. In other words, TennCare health plans could pick and choose what treatment and services they want to cover, with no oversight from the federal government. This would amount to rationing of health care just to save money.  This proposal is harmful to individuals with mental illness or substance use disorder who would otherwise benefit from prevention, treatment and recovery services. As members of NAMI Tennessee, my wife and I have experienced a member of our family (our son) being on  TennCare. Our son had a mental illness. He died by suicide. In spite of the help he got from some of the most  dedicated health care providers, finding the proper medication balance was impossible.      By limiting the drug choices per “therapeutic class” this new proposal would limit the flexibility which is  absolutely needed to treat complicated mental health cases.  81    We strongly urge you to reconsider this proposal!     Ann & Frank Zingheim,  Crossville, TN  frzingh@citlink.net  (931) 707‐5303         82 Jonathan Reeve From: Sent: To: Subject: Michael O'Malley Monday, October 7, 2019 9:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   TennCare,    I must add my voice to the widespread dissent over Gov. Lee's proposal to adopt the modified block grant for TennCare.  The governor says that this proposal will potentially save the state of Tennessee money, but when it comes to  healthcare and providing for the livelihood of human beings, fiscal savings should never be traded for services‐‐ especially not in a state where the number of uninsured residents increases yearly. I am aware that Lee says that there  will be no loss of services as a result of this proposal, but any honest assessment of this proposal must admit that it at  least opens the door for a loss of services in the future. The governor talks about giving the state more flexibility, but a  state that has fought tooth and nail for years to resist a Medicaid expansion should not be trusted with flexibility in how  it offers healthcare services. There is nothing about Lee's proposal that stops the state from cutting TennCare services in  some future budget "crisis"? I am not willing to gamble on the healthcare future of our state.    People's lives are on the line. This proposal is not an acceptable response to a life‐or‐death situation.    Sincerely,  Michael O'Malley  Knoxville, 37914  83 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of kchiles1@gmail.com Monday, October 7, 2019 9:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Katy Chiles  2105 Buckingham Circle  Maryville, TN 37803‐6504   84 Jonathan Reeve From: Sent: To: Subject: kchiles1@gmail.com Monday, October 7, 2019 9:26 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the proposed Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear all,    I oppose the proposed Block Grants because it would give Tennessee new authority to cut services for children,  seniors, low‐income parents, and people with disabilities.     Katy Chiles  2105 Buckingham Circle  Maryville, TN 37803    kchiles1@gmail.com  85 Jonathan Reeve From: Sent: To: Subject: jwhite55@everyactioncustom.com on behalf of James White Sunday, October 6, 2019 4:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    The administration has provided no assurance that the proposed Medicaid Block Grant Proposal will improve the heath  and welfare of Tennesseans. If Governor Lee and his administration has a worthy solution, they should be able to explain  it in simple terms and commit to the objectives of not only improving health coverage to all Tennesseans who are  eligible for basic Medicaid, but also add the more than 300,000 Tennesseans who should be covered under the Medicaid  expansion plan available under the Affordable Care Act. When our neighbors suffers from poor health we all suffer  through their lack of well being and ability to make a productive contribution to our communities.    Sincerely,  James White    Sincerely,  James White  5506 W Shady Trl  Old Hickory, TN 37138‐1320 jwhite55@tds.net  86 Jonathan Reeve From: Sent: To: Subject: DAVIDW.GREGORY@everyactioncustom.com on behalf of David Gregory Sunday, October 6, 2019 6:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] My patients who rely on Tenn-Care deserve more, not less in health services.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. David Gregory  3813 Estes Rd  Nashville, TN 37215‐1730  DAVIDW.GREGORY@COMCAST.NET  87 Jonathan Reeve From: Sent: To: Subject: lbrooks@everyactioncustom.com on behalf of Lisa Brooks Monday, October 7, 2019 5:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lisa Brooks  220 Athens Way  Nashville, TN 37228‐1311 lbrooks@gnrc.org  88 Jonathan Reeve From: Sent: To: Subject: Tony Garr Sunday, October 6, 2019 5:31 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment #1: Tennessee Does Not Need a Block Grant to Save Billions in order to Keep Half of It   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   One of the reasons for Tennessee asking for a Block Grant is that none of the money that it is saving the federal  government now, and has since its inception in 1994, is coming back to the state. All the funds that TennCare has saved  the federal government has reverted back to the federal government. TennCare claims that the savings to the federal  government since 1994 are in the billions.    If this is the case, then why not ask that these savings be shared with Tennessee as part of the current 1115 waiver  using its current funding/matching agreement? Why would Tennessee want to unnecessarily restrict funding from the  federal government by asking for a Block Grant to retain some or part of the savings? Amendment 42 makes the  argument that TennCare has saved the federal government billions and that the incentives are misaligned, meaning that  the more the state spends on its Medicaid program, the more the federal government will spend according to the match  rate. In Tennessee, this match rate is about 35% State and 65% federal funds. So, Tennessee argues that if the state is  willing to take the risk and Cap what it gets from the federal government, then, if successful, it needs to benefit  financially from these savings. The state is asking that it should be able to retain 1/2 of all the savings.  TennCare has proven that it can run a very efficient program and that it can keep its spending below the neutrality cap  that is pre‐determined by the Congressional Budget Office. It has been able to do this since the beginning. Of course,  TennCare is incentivized to do this because if it goes over its neutrality budget cap, then it will have to go back to the  state legislature and ask for supplemental funds, a common practice before the creation of TennCare in 1994. In  addition, if TennCare goes over its neutrality cap, then TennCare would lose its federal match and would be required to  pay 100% of the costs above the neutrality cap.  Since the inception of Medicaid in 1965 in Tennessee, it was a common occurrence for its Medicaid program to ask for  supplemental funding during the year in addition to its annual budgeted funds from the state legislature. This occurred  because medical inflation was and still is about twice that of regular inflation and tax dollars were not and have never  increased at twice that of regular inflation. To stay within its budget, its Medicaid program, which was primarily a fee‐ for‐service program, would either cut benefits, cut reimbursement to doctors and hospitals, or ask for supplemental  funds. When reimbursements were reduced to providers, the likely scenario was that providers would drop out of the  Medicaid program and no longer accept Medicaid.  When benefits were cut or reduced (for example: hospital stays  being restricted to 10 days/year), it would result in many hospitals not getting paid for patients who needed more than  10 inpatient days.  Providers would have to either not provide the care, shift the costs to paying patients, or reduce the  amount of care.   With the creation of TennCare in 1994 and the conversion from a fee‐for‐service to a managed care organization system,  and after about a decade of turbulent start‐up years with unstable managed care organizations, TennCare  finally  developed a stable, mature network of MCOs. This stabilized the TennCare budget, making it more predictable and  easier to budget. Since 1994, the managed care organizations, not the state, had been at risk for losing money.  89 Now the state is proposing a Block Grant through Amendment #42 which operates like a Capitation Program, putting the  TennCare program at risk because the amount that it will receive from the federal government will be fixed, based on  the number of people being served, with inflation being based on ordinary inflation not medical inflation which is always  higher. TennCare is saying that its track record is such that this is not a concern, that no one will lose their care and  providers will not be cut.  This begs the question: Why is Tennessee requesting a Block Grant when the program can continue to be efficient and  save money despite medical inflation? Why not just ask the federal government for half the savings that it creates  annually under the current funding/matching agreement?  Take care,    Tony Garr  259 Graylynn Drive  Nashville, TN  37214  tgarrthcc@gmail.com  615‐603‐9747      90 Jonathan Reeve From: Sent: To: Subject: Mary Held Sunday, October 6, 2019 12:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Unequivocally opposed: TN Medicaid Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom it May Concern,    I am unequivocally opposed about the  TN Medicaid Block Grant Proposal.  This proposal will have a negative and harmful impact on the most vulnerable individuals in Tennessee ‐ the exact  people whom Medicaid was created to serve. They will bear the brunt of this proposal. Regulation of managed care  organizations are vital to both patients and program integrity.    Half of children in Tennessee and 60% of nursing home residents rely on TennCare to have good health and medical  well‐being. Cutting these funds will make the most vulnerable residents in our state at much greater risk of unmet  health needs, which will elevate use of emergency rooms for routine care and will result in unmet physical and mental  health needs. That puts, as a state, in a crisis situation in which individual lack equal access to care. When youth have  unmet needs, they will not excel in school and will have elevated behavioral problems, leading to increased problems  throughout life ‐ that can result in intergenerational complications and far more expenses on our social system.    This proposal is an unfair and unacceptable to cut that will result in significant harm to a large proportion of TN  residents. When any TN residents are harmed, everyone ‐ and especially the most vulnerable ‐ are affected.    Thank you for hearing my strong concerns and opposition to this proposal.    Mary Held  91 Jonathan Reeve From: Sent: To: Subject: Payne, Shelby Saturday, October 5, 2019 5:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Take Action to Oppose the Medicaid Block Grant Proposal!   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am opposed to this proposal.     Thank you,  ‐‐   Shelby Payne  Master of Science in Social Work Candidate Spring 2020  University of Tennessee College of Social Work  School email: spayne19@vols.utk.edu  Personal email: payneshelby93@yahoo.com    92 Jonathan Reeve From: Sent: To: Subject: jjc.howard@everyactioncustom.com on behalf of William Culbert Saturday, October 5, 2019 3:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grants. Big mistake     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    A study of 14 Medicaid expansion states by the Urban Institute found that the improved business environment of the  expansions paid for the costs incurred by the states. Using block grants to save medical costs through dis‐enrollment and  disregarding many protections of the ACA is highly regressive, cruel for those with chronic medical conditions, and  economically irrational. In fact, it is the opposite of expansion. For example, hypertension is now the leading cause of  death in the world. One in three American adults have it and half don’t have it under control. Diabetes and the pre‐ diabetic condition metabolic syndrome are epidemics, especially in TN. At least half of the patients on dialysis are there  from delayed or under treatment of these conditions. Access to quality primary care can effectively treat or prevent  them for a few hundred dollars a year. Dialysis costs $90K a year for life. Treatment for congestive heart failure as a  product of under treatment of these conditions is one of the five most expensive hospitalization diagnoses in the U.S.  Tennessee leads the nation in rural hospital closures per capita. This is six‐times more likely to occur with non‐ expansion. These are the highest paying jobs in rural counties and create more than two jobs in the non‐healthcare  sector per each healthcare job representing anchors in these communities. Few businesses would locate in a county  without a hospital. The gross instability of this market created with block grants will hasten the process, further  impoverishing rural Tennesseans. Health care in the U.S. costs twice the average for the other 34 rich nations and they  all provide universal coverage. Despite this, we have among the worse health outcomes, especially in maternal and  infant mortality and general longevity. Further restriction of block grants is a political end run around the ACA and has  no precedent for long‐term cost savings or patient wellbeing.     Sincerely,  Dr. William Culbert  106 Deerfield Ln  Oak Ridge, TN 37830‐8767 jjc.howard@gmail.com  93 Jonathan Reeve From: Sent: To: Subject: handds2004@everyactioncustom.com on behalf of Dianne Hand Saturday, October 5, 2019 10:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program. We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Dianne Hand  120 Woodland Rd  Winchester, TN 37398‐4424 handds2004@yahoo.com  94 Jonathan Reeve From: Sent: To: Subject: John Jivens Friday, October 4, 2019 8:48 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Say No to Block Grant!     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Tennesseans deserve better. No to Block Grant  Tennesseans need health care!!!!!    Sent from my iPhone  95 Jonathan Reeve From: Sent: To: Subject: Kay Knox Friday, October 4, 2019 4:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern:    For our Governor and Legislature to be even considering this Block Grant proposal for the State of Tennessee versus  expanding Medicaid is absolutely ruthless and without regard to any in our State who are without health care, local  hospitals and living in poverty!  This Block Grant only serves the medical community, pharma and the State  Government.  It may help reduce what the State has to pay for health care but puts even more of our citizens at risk.  It  does nothing to assist those without health insurance, or to relieve the hospital closings in our rural and poorest  areas.  Our new “religious and Christian” Governor should be looking for ways to help the people of Tennessee rather  than approving a program which will cause them more harm in an effort to save the State money.     I have a very dear friend who lives in Iowa.  Over the last few years he has had some terrible health care events in his life  which had him worrying about how to pay the bills.  He lost his home and car and had to find a place to live with  affordable senior housing rates in his small town of 4,500.  He has always been  a very committed Republican.  He would  not be alive today if his wise Governor and State Legislative bodies hadn’t approved the expansion of Medicaid in the  state of Iowa!  The day he received the unexpected and un‐applied for notice of his acceptance into the expanded  program he gave me a very excited phone call.  The first words out of his mouth that day were, “Thank God for President  Obama!”  He had not originally liked the ACA (Obamacare) until it saved his life! He has even started supporting some  Democratic candidates who have a broader view of health care issues.  I would be willing to bet that there are hundreds  possibly thousands of horrible health care stories of families in Tennessee who have wound up in bankruptcy because of  health care problems…but unfortunately our Tennessee stories are not going to have the same happy ending that his  did.    This Block Grant will NOT keep our hospitals from closing.  It will NOT solve the problem of high medical costs, even  though they say it will.  What if the medication someone’s physician wants them to take is not on the list of acceptable  medications covered under the Block Grant? Our citizens should NOT have to decide whether to buy outrageously  expensive but necessary and life‐saving medication or buy food, pay electric bill, or pay rent!  It will NOT do anything  about covering the over 600,000 who are currently without health insurance and according to what I have read will  possibly put an additional 300,000 people into the category of uninsured.  There are too many loop‐holes in Amendment  12 that will allow the State to change the rules that will leave out more people than it helps.     Have you ever wondered why the 36 States which have made the decision to Expand Medicaid within their state haven’t  chosen to settle on a Block Grant?  And “SETTLE” is the intended word!  Well one reason is that those states put their  citizens FIRST!  It appears that those states CARE more about their citizenry than Tennessee does.  Those states  understand that healthy citizens create a healthier economy.  The main reason for not choosing a Block Grant is so  simple a sixth grader could figure it out!  The Block Grant doesn’t work!!!  If the Block Grant works so beautifully to  protect the health and welfare of citizens, one would assume that at least one of  those 36 other states would chosen  the Block Grant path…but they didn’t!  Are they smarter than Tennessee?  Maybe.  Did they even consider a Block  Grant?  Maybe.  Did they understand that their state was paying tax dollars that were going to other states to pay for  health care there?  Maybe.  Did they realize that, as Tennessee is currently doing, they were forfeiting approximately  96 one BILLION dollars per year over the last decade or so that would cover the costs for health care for their  citizens?  Maybe.  But one thing is certain…they didn’t choose a Block Grant!       Our new Governor and Legislature have been very successful in making the State of Tennessee a laughing stock.  The  entire country has been laughing at recent legislation and enjoyed reading about a Catholic Priest who banned a series  of books for the make‐believe spells…we appear to be backward and uneducated instead of educated and forward  thinking.  I have lived in Nashville my whole life and I have always been proud of my city and state.  We have thousands  of people moving to Tennessee looking for a better way of life.  All we appear to be doing is shooting ourselves in the  foot.  I have had conversations with several who have recently moved to Tennessee and are rethinking their choice.     This Block Grant is NOT a good thing for Tennessee!  We can do much better for our people and our State.  I expect  more from our elected officials.  I do have one question for all of them…Would they be willing to forfeit their current  state supplied health insurance (the one we pay for, for the rest of their lives) for the Block Grant coverage they are  proposing?  If their answer is a resounding NO, which I assume it would be, then they know as well as I do that they can  do better!    The simple answer is EXPAND MEDICAID IN TENNESSEE!    Leslie Kay Knox  2209 Abbott Martin Rd. #7‐2  Nashville, TN   37215‐2512    97 Jonathan Reeve From: Sent: To: Subject: clairejlovelace@everyactioncustom.com on behalf of Claire Lovelace Friday, October 4, 2019 11:58 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” Many vulnerable Tennesseans would most likely lose their coverage;  losing coverage would cause great harm. Can you imagine what would happen to you if you lost your access to quality  health care?  I would certainly panic if I faced that possibility!    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations.  In my volunteer work, I come in contact regularly with the  most vulnerable citizens of my community.  I now a "block grant" would affect many of them negatively.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed. It goes against the goals and purpose of the Medicaid program. I respectfully urge  you not to go forward with this harmful proposal.          Sincerely,  Ms. Claire Lovelace  100 Netherland Ln Apt 302 Kingsport, TN 37660‐7248 clairejlovelace@hotmail.com  98 Jonathan Reeve From: Sent: To: Subject: torymills@everyactioncustom.com on behalf of Tory Mills Friday, October 4, 2019 2:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I work for a health care provider, and many of our patients are only able to get the care they need because they are  insured through TennCare. As a lifelong Tennessean, I am saddened that values I hold dear ‐ taking care of our neighbors  and valuing families and children ‐ are being left behind when an opportunity for potential cost savings arises. I am  increasingly fearful for my family members, like my 92 year old grandmother, who rely on programs like Medicaid. I  hope that Tennessee will become a state that does not care for the poor, the sick, and the most vulnerable.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Tory Mills  2412 Amber St  Knoxville, TN 37917‐4033  torymills@gmail.com  99 Jonathan Reeve From: Sent: To: Cc: Subject: James S. Kennedy MD Friday, October 4, 2019 1:33 PM PUBLICE NOTICE TENNCARE Charlie Baum; sen.dawn.white@capitol.tn.gov [EXTERNAL] Amendment 42 comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To the Governor and all concerned:    I am not opposed to Tennessee’s application for a block‐grant funding of Medicaid and release from burdensome  regulations that impede the effectiveness of the program; however, I am fearful of the adequacy of the funding in your  Amendment 42 and ask that you implement my recommendations.    While I do not oppose that your basing your current funding on CMS’s projection of providing care to the TennCare  population, I ask that this funding be Indexed according to a commonly used risk‐adjustment algorithm, such at the  University of California San Diego CDPS+Rx methodology, and that further funding be made not just on population  growth in various categories but also on the severity or resource intensity of the illnesses within Tennessee’s population  as reflected in an increase or decrease of this CDPS severity index.   I believe we would be naïve to assume that the  illness of the past 3 years will be the same of the next 3 years; having this Index in place recognizes that epidemics can  occur, such as the Vaping‐Induced Lung Injury Syndrome which, if properly documented and coded in ICD‐10‐CM, better  reflects the resource intensity encountered by Tennessee’s physicians and hospitals.   CMS uses a similar methodology  for risk‐adjustment with its Medicare Advantage (CMS‐HCCs) and its PPACA plans (HHS‐HCCs); the state of Tennessee  should do the same.      The data set guiding this Index should also not just be based on Tennessee’s claims but any claim that has been  submitted on the patient’s behalf in Tennessee or other states.   One problem Tennessee had in its implementation of  TennCare in 1994 was that upon implementation, many individuals moved from other states to Tennessee to qualify  themselves for our generous benefits package that was not available in other states, such as Kansas.   We should be able  to risk‐adjust for these patients who come into our system so that we have the appropriate funding.    I believe that even with Indexing your funding will not be adequate to support the level of services demanded by  Tennesseans, especially those with access to the media, or to maintain adequate provider networks acceptable to  politically‐active citizens or physicians.   I believe that you should have other sources of funding to meet goals presented  in the media which, of course, is politically sensitive but something that can be sold, such as the false‐hope schemes of  the Tennessee Lottery who prey upon human nature in the name of education.   Options include:     Dedicated funding from alcohol, nicotine, or opioid sales, given that these substances contribute greatly for the  need for Medicaid (e.g. 5 cents per ounce of alcohol; 25 cents per pack of cigarettes)   Dedicated funding from gasoline taxes that support trauma networks and transportation to these networks,  especially from the rural parts of Tennessee (e.g. 2 cents a gallon)   Expanding Medicaid according to what is allowed under the PPACA   Considering premiums based on a patient’s body mass index as an incentive to not overeat or to increase  physical activity.    I would be glad to travel to Nashville to discuss these options with you.  Should you have any questions about CDPS, I  encourage you to contact Dr. Todd Gilmer at UCSD, at the following ‐ https://innovation.ucsd.edu/contact/.    100   I thank you for your willingness to consider my comments.      James S. Kennedy, MD, CCS, CCDS, CDIP                                                                                           President ‐ CDIMD – Physician Champions  Executive Assistant:  Brandie Justice – brandie@cdimd.com – (615) 906‐4051 – feel free to write or call as needed.    110 Frances King Drive, Suite A‐1  Smyrna, Tennessee 37167‐5352  jkennedy@cdimd.com  (615) 479‐7021 – Cellular  (888) 425‐2346 – electronic fax – sent securely to jkennedy@cdimd.com   (615) 223‐6962 – Office Telephone    101 Jonathan Reeve From: Sent: To: Subject: BRITTFIDDLE@everyactioncustom.com on behalf of Brittany Haas Friday, October 4, 2019 9:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     These cuts would undermine those least able to afford health care ‐ especially those who already face barriers to care,  like people with low incomes, communities of color, individuals with disabilities and people in rural areas.    As a leading provider of reproductive health that sees Medicaid patients every day, Planned Parenthood understands  that reproductive health is at particular risk if Medicaid is block granted. Any attempt to paint these proposals as  anything but harmful or dangerous are misleading and ignore that reality that women ‐‐ and women of color in  particular ‐‐ would face even greater inequity in health care access and poorer health outcomes.     The Medicaid program is a critical resource for preventative health services that millions of women rely on including  family planning services and pregnancy‐related care.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Brittany Haas  Nashville, TN 37216  BRITTFIDDLE@GMAIL.COM  102 Jonathan Reeve From: Sent: To: Subject: DebraS3786@everyactioncustom.com on behalf of Debra Smith Friday, October 4, 2019 9:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tennessee Block Grant Proposal - Citizen Response   Dear Gabe Roberts,    Having read the block grant proposal as well as studying research related to block grants, it is clear that the block grant  proposal seeks to turn Tennessee's most vulnerable citizens into experimental test subjects. There is no evidence that  the proposal would lead to better health outcomes or increased coverage. As a Christian, this proposal is inconsistent  with the tenants of my faith community. I hope the state of Tennessee will reconsider moving forward with seeking  authorization for such a risky plan.    Sincerely,  Rev Debra Smith  115 N Timber Dr  Nashville, TN 37214‐4253 DebraS3786@comcast.net  103 Jonathan Reeve From: Sent: To: Subject: ddavisx7@everyactioncustom.com on behalf of Debra Davis Friday, October 4, 2019 12:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    My mother is 88 years old and disabled. Her current cost of care is supplemented by the Tenncare Choices program.  Without Tenncare, I would be unable to meet her financial and healthcare needs.  I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Debra B. Davis     Sincerely,  Debra Davis  Nashville, TN 37214  ddavisx7@gmail.com  104 Jonathan Reeve From: Sent: To: Subject: phopkins4619@everyactioncustom.com on behalf of Pamilla Hopkins Friday, October 4, 2019 1:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I am a senior. I'm not on Medicaid but I know people who have it. It's their lifeline.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Pamilla Hopkins  1900 Acklen Ave Apt 1608 Nashville, TN 37212‐3731 phopkins4619@yahoo.com  105 Jonathan Reeve From: Sent: To: Subject: nanabowlin@everyactioncustom.com on behalf of Linda Bowlin Thursday, October 3, 2019 9:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Linda Bowlin  Kingsport, TN 37660  nanabowlin@yahoo.com  106 Jonathan Reeve From: Sent: To: Subject: valleygirl9@everyactioncustom.com on behalf of Traci Worley Thursday, October 3, 2019 9:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Traci Worley  346 New Canton Rd  Church Hill, TN 37642‐4257 valleygirl9@hotmail.com  107 Jonathan Reeve From: Sent: To: Subject: valleygirl9@everyactioncustom.com on behalf of Traci Worley Thursday, October 3, 2019 9:27 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Traci Worley  346 New Canton Rd  Church Hill, TN 37642‐4257 valleygirl9@hotmail.com  108 Jonathan Reeve From: Sent: To: Subject: kathythefireescape@everyactioncustom.com on behalf of Kathy Christian Thursday, October 3, 2019 9:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] No block grant!!Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathy Christian  541 Wilson St  Church Hill, TN 37642‐3531 kathythefireescape@yahoo.com  109 Jonathan Reeve From: Sent: To: Subject: ahrens@everyactioncustom.com on behalf of Kaitlyn Partin Thursday, October 3, 2019 7:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Kaitlyn Partin  Johnson City, TN 37615  ahrens@etsu.edu  110 Jonathan Reeve From: Sent: To: Subject: mmiddl9469@everyactioncustom.com on behalf of Mary Jo Middlebrooks Thursday, October 3, 2019 12:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mary Jo Middlebrooks  PO Box 1985  Jackson, TN 38302‐1985  mmiddl9469@aol.com  1 Jonathan Reeve From: Sent: To: Subject: alarogr@everyactioncustom.com on behalf of Alana Green Thursday, October 3, 2019 12:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Although I am not on TennCare, I know how important it is for vulnerable Tennesseeans to have access. Basically, if you  support this block grant, you are privileging saving dollars over life saving medical care.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Alana Green  606 S 13th St  Nashville, TN 37206‐3072  alarogr@gmail.com  2 Jonathan Reeve From: Sent: To: Subject: kbandcf@everyactioncustom.com on behalf of Kathryn Beasley Thursday, October 3, 2019 12:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathryn Beasley  907 Sutton Hill Rd  Nashville, TN 37204‐3023 kbandcf@gmail.com  3 Jonathan Reeve From: Sent: To: Subject: alice.legard@everyactioncustom.com on behalf of Alice Legard Thursday, October 3, 2019 2:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Alice Legard  2530 W State St  Bristol, TN 37620‐1816  alice.legard@fmc‐na.com  4 Jonathan Reeve From: Sent: To: Subject: rebekahhl@everyactioncustom.com on behalf of Holly Latham Thursday, October 3, 2019 8:01 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I am not on TennCare but I am very concerned for those who are and those who might be. Any one of us could need  TennCare's services at any time. We should want TennCare to be something we are proud of in Tennessee. We want to  take care of our citizens. I do not agree with the loss of required federal standards.     I have experience with the requirement benefits of federal standards as a disabled mom of a child who needs an IEP in  school. Those federal requirements help her have access to education. Federal requirements help me have access to  buildings while in my wheelchair. I wish I trusted my state to be diligent and provide so much better than the minimum  federal requirements.  Your track record has not earned my trust. We have lost so many rural hospitals. The infant  mortality rate is frightening. Trust should be earned and you fall short.     I will not stand by and let my fellow Tennesseans suffer and lose services. I believe the loss of federal requirements will  hurt every single Tennessean on TennCare or not.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Holly Latham  15 Glen Dillon Dr  Jackson, TN 38305‐7837 rebekahhl@yahoo.com  5 Jonathan Reeve From: Sent: To: Subject: duckdoc1945@everyactioncustom.com on behalf of william shannon Thursday, October 3, 2019 11:43 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal by Parent of Disabled Son   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal  funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.  As a parent of a 48 year old son who is totally disabled, I can share with you that it has taken an army of folks and  services to get him to who he is today. You see, he is nonverbal and quadriplegic‐he cant walk or talk but with his  brilliant mind , he has overcome the handicap of cerebral palsy!  He has a master's degree in CIS and a full time job! He will tell you that he is happy with the life God has given him!  Family,church family, Vocational  Rehab. Technical Access Center ,Bill Wilkerson Center,Sumner County School  System,U.T. Rehab Engineering, Higher education at Vol State and Bachelors degree and Masters at MTSU ‐all have been  involved in getting him to this point of education!  TennCare Choices Program has been a major factor in providing him attendant care and health care for the last few  years! It would be tragic for him! for these services to be decreased.  We in Tennessee have made a huge investment in this man who has overcome seemingly insurmountable obstacles to  become a happy and productive member of society! He has paid us back in spades with his life!  An extremely wise mentor in my field as a Veterinarian, told me years ago , don't be the first nor the last to make a  change in your treatment decisions‐your patients will benefit!   I also see no logical way to fund the TennCare recipients on a per capita basis,especially knowing the vast  differences in  degree and extent of disability and illness. Ones size doesn't fit all!  As a society, we deem life to be precious‐any life! It deeply concerns me that chronically ill or disabled people would be  subject to a tax saving idea! it should be the opposite! i know no one who would decry doing the best for this part of our  population.  I oppose the Block Grant Proposal! William G. Shannon,D.V.M.    Sincerely,  Dr. william shannon  137 Bayshore Dr  Hendersonville, TN 37075‐4602 duckdoc1945@gmail.com  6 Jonathan Reeve From: Sent: To: Subject: Paul Dougherty Friday, October 4, 2019 9:45 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposed to Block Grant Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   As a businessman and a Christian, I am writing in opposition to Amendment 42. It is short‐sighted with  consequences that will reduce the livability of our communities. When I hear proponents of the Block Grant  say it's not the intent "under this proposal to reduce covered benefits for members below their current  levels", I'm reminded of Barrack O'Bama's claim "You can keep your doctor." Neither are true.    Our economy is booming, we have billions in our state and investing in our state. Now is not the time to  increase our riches on the backs of the least fortunate among us. Even though I am well off, I know we are all  one misfortune away from needing the help of our neighbors.    Adopting this narrow‐minded approach and leaving federal dollars on the table will not help Tennessee.  Instead fight for the conservative capitalist right to negotiate the price of drugs.    Best regards,    Paul Dougherty  231 Green Harbor Rd, Unit 130  Old Hickory, TN 37138  7 Jonathan Reeve From: Sent: To: Subject: shelly L Thursday, October 3, 2019 11:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL]   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I highly am against the block please rethink cause i know several people that can't afford to lose their tenncare!!!!    Please listen to us there's no reason for a block  8 Jonathan Reeve From: Sent: To: Subject: Laura Mallette Thursday, October 3, 2019 11:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Comment: It is NOT the right thing   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   TennCare Caretakers, I trust that you have best interest of those your serve (and need your service, but don;t currently qualify) as your priority. Please read my comments AGAINST the Medicaid Block Grant proposal and listen to the experts who are speaking up at public hearings. The proposal DOES NOT provide better health care to Tennesseans and also DOES NOT provide health care to more Tennesseans. What then is the purpose of this proposal? More than 200,000 low-income adults in Tennessee are uninsured because of Tennessee’s failure to expand Medicaid: their incomes are too high for Medicaid but too low to qualify for tax credits to buy marketplace coverage. The health of these Tennesseans is at increased risk relative to those living in other states because Tennessee has refused to accept the Medicaid expansion dollars APPROVED by the federal government and FUNDED by our tax dollars. This is total irresponsibility on the part of our legislature! Under federal law, Medicaid waivers are required to promote the program’s central goal of providing health coverage to low-income people. The proposed Medicaid Block Grant program will do NOTHING to address Tennessee’s coverage gap. It isn’t an alternative to Medicaid expansion! The waiver proposal does not expand TennCare eligibility to any uninsured low-income adults. Adopting Medicaid expansion would cover this group and avoid the waiver’s many pitfalls and dangers. Moving to the block grant will only further reduces the federal health care dollars coming to Tennessee. The legislature goal seems to be reducing spending, not providing health care, so as the state makes cuts in health care spending (and shares half of that savings with the federal government!) the health of Tennesseans will suffer. The block grant proposal is just another way for Tennessee lawmakers to give away the portion of our federal taxes that should be serving the health care needs of our residents.  Laura Mallette  ‐‐   Laura Mallette  847 Stonegate Shores  Dandridge, TN 37725  865‐712‐7743 (cell)  9 Jonathan Reeve From: Sent: To: Subject: Kathryn Kiper Thursday, October 3, 2019 10:58 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am writing to express my opposition to the efforts by the Governor to get Block Grants for Tennessee. The action  considered is irresponsible, lacks accountability, will take patient care further out of the hands of medical professionals  and place it at the whim of government officials.    In addition, it does nothing to actually extend coverage for Tennesseans and will certainly jeopardize the care of over 1  million of Tennessee's most vulnerable.     Governor Lee and those working with him to procure these block grants hope to exchange the necessary care  Tennesseans need through Medicaid for "flexibility" in how they may use this money. This most certainly will result in  worse coverage, not better.    As a life‐long Tennessean, I want to express my deep opposition to the Block Grants and to ask that we take the  Medicaid expansion money. We've been paying for this in Federal taxes and have let the money go to other states. It's  time to fully expand medicaid and improve our state's healthcare with models such as our neighbor Kentucky.     Regards,    Kathryn Kiper  Dayton, Tennessee  37321  10 Jonathan Reeve From: Sent: To: Subject: martom3@everyactioncustom.com on behalf of thomas peck sr Thursday, October 3, 2019 6:43 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal - Please stop this proposal this grant affects those who can least afford ANY ADDITIONAL EXPENSES TO THEIR DAILY LIFE. Please look at this as if you or any of your family are in any of these sit...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  thomas peck sr  126 Niwodihi Trl  Vonore, TN 37885‐2699  martom3@tds.net  11 Jonathan Reeve From: Sent: To: Subject: tennesseeswiderek@everyactioncustom.com on behalf of Jodi and Ben Swiderek Wednesday, October 2, 2019 8:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal   Dear Gabe Roberts,    We urge you to vote against the proposal to convert federal funding for TennCare into a “block grant.” This move might  bring some short‐term relief to the state budget, but in the long run it will end up costing the state more due to  problems related to removing this needed coverage.    I (Jodi) work for an organization called CASA Monroe (Court Appointed Special Advocates).  We speak up for abused and  neglected children in Juvenile Court.  We work with people who have numerous problems which, of course, filter down  to their children.  One of the saving graces for these children is that they are able to obtain health care through our  Medicaid system.  Without this coverage, children would go untreated and we would see problems in the schools, in the  foster care system, in the hospitals (which already handle too many non‐payers), in rehab centers, etc.    The question is how do you control what happens to our most vulnerable citizens when TennCare loses its federal  oversight and is now at the mercy of any future governor or elected official who wants to cut it even further?     The block grant proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut  services for our most vulnerable populations ‐ children, pregnant women, people with disabilities, etc. The state could  eliminate or restrict services like physical therapy, hospice, and transplant coverage without normal federal oversight –  and arbitrarily limit who gets them. The proposal could also cut back on core health care services like hospital care,  without federal approval or public notice, and exclude coverage of the most effective prescription drugs.     When we came to Tennessee many years ago, we were extremely impressed with the TennCare program.  It reflected a  state that cared about and took care of its citizens.  It was ahead of its time.  It was studied and coveted by many other  states.  And, it was effective and far‐reaching.  Over the years, however, it has been whittled down to a bare minimum.   This latest move to turn it into a block grant will remove any accountability it has, with Tennesseans as the victims.    Changing our current Medicaid program has serious repercussions. The repercusssions are like weeds ‐ they pop up all  over and are very expensive to get rid of, if you are even able to.    Please vote against this Medicaid Block Grant Proposal.        Sincerely,  Jodi and Ben Swiderek  714 Scenic River Rd  Madisonville, TN 37354‐6518 tennesseeswiderek@netzero.net  12 Jonathan Reeve From: Sent: To: Subject: jdareblake@everyactioncustom.com on behalf of Jasmine Blake Wednesday, October 2, 2019 8:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jasmine Blake  Gray, TN 37615  jdareblake@gmail.com  13 Jonathan Reeve From: Sent: To: Subject: janeyosborne@everyactioncustom.com on behalf of Janey Reid Wednesday, October 2, 2019 8:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Janey Reid  Johnson City, TN 37601  janeyosborne@gmail.com  14 Jonathan Reeve From: Sent: To: Subject: psimon901@everyactioncustom.com on behalf of Elaine Simon Wednesday, October 2, 2019 11:04 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Elaine Simon  75 Mitchell St  Hornsby, TN 38044‐4045  psimon901@aol.com  15 Jonathan Reeve From: Sent: To: Subject: derainey67@everyactioncustom.com on behalf of David and Tish Rainey Wednesday, October 2, 2019 4:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As people of faith, we are opposed to the proposal to change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.”            In our view ‐ and that of many others we know ‐ the block grant approach poses a considerable and unnecessary  risk to the health of our state's most needy and vulnerable citizens.  At a time when a large number of our people are  already uninsured, we would support Medicaid expansion in Tennessee and are alarmed that this has not yet been  pursued by our state's leadership.  The block grant proposal seems primed to transfer federal funds available for health  care to other programs in the name of "savings."  We believe that in the long run this will actually cost more in poorer  health and closed rural hospitals.  The block grant program is simply short sighted.  No wonder it is opposed by so many  health care advocates.  Tennessee can do better than this.         David and Tish Rainey       Sincerely,  Rev. David and Tish Rainey  2702 Hillmeade Dr  Nashville, TN 37221‐5221 derainey67@gmail.com  16 Jonathan Reeve From: Sent: To: Subject: ajonfrere@everyactioncustom.com on behalf of Jon Frere Wednesday, October 2, 2019 4:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jon Frere  2109 32nd Ave S  Nashville, TN 37212‐4042 ajonfrere@gmail.com  17 Jonathan Reeve From: Sent: To: Subject: sean.muldoon@everyactioncustom.com on behalf of Sean P.Muldoon Wednesday, October 2, 2019 4:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.”     Why? you ask........so the simple facts are    1. This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.   2. This waiver is fundamentally flawed and cannot be fixed.  3. It goes against the goals and purpose of the Medicaid program.  4. This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for  these vulnerable populations.   5. This proposal invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.     Equally as important, this proposal is based in politics and not in what is fundamentally right and needed to care for the  poor and fragile of our State. It was created in opposition to the Affordable Care Act as opposed to in an effort to  improve the health and well‐being of the members of the State. It openly rejects the opportunity to increase funding  that would demonstrably improve lives. Finally it flies in opposition to a chorus of bi‐partisan proponents of an  expansion program (not this trash) endorsed and embraced by experts in the  healthcare, public and private  sectors...and if implemented by the general populous.    This administration ran on smart programs to build Tennessee....then do it....reject this "crap proposal" and work  collectively to improve TennCare through the proven opportunities of Medicaid expansion.    I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Sean P. Muldoon  105 Briar Oaks Ct  Old Hickory, TN 37138‐4213 sean.muldoon@att.net  18 Jonathan Reeve From: Sent: To: Subject: annvdl01@everyactioncustom.com on behalf of Ann Van der Linde Wednesday, October 2, 2019 5:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] If the Republican leadership cared as much about people as it does about money and its Rainy Day Fund, Medicaid would have been expanded years ago. Take care of your citizens, not just your bottom Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Ann Van der Linde  136 Westwood Ave  Jackson, TN 38301‐4320 annvdl01@gmail.com  19 Jonathan Reeve From: Sent: To: Subject: bilqis.rock@everyactioncustom.com on behalf of Bilqis Rock Wednesday, October 2, 2019 6:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Strongly Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am strongly opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans.     As a clinical social worker and Memphis resident, I'm appalled at the proposal's intention to restrict health care services  to vulnerable Tennesseeans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Bilqis Rock  489 Stonewall St  Memphis, TN 38112‐4901 bilqis.rock@gmail.com  20 Jonathan Reeve From: Sent: To: Subject: louisrice51@everyactioncustom.com on behalf of Louis Rice Wednesday, October 2, 2019 12:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant is untested and unwise!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Louis Rice  201 Kentucky Ave  Sewanee, TN 37375‐2101 louisrice51@gmail.com  21 Jonathan Reeve From: Sent: To: Subject: jstewartlaw865@everyactioncustom.com on behalf of Jessica Stewart Wednesday, October 2, 2019 12:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, and the group that will suffer the most is the one with the least capacity to make  their voices heard in the public discourse, i.e., the elderly.     The majority of elderly Tennesseans are in need of some level of specialized care, but cannot keep up with today's  exorbitant costs for such services. I have seen it first‐hand countless times when I worked as the managing attorney for  the federally‐funded Legal Assistance for the Elderly Program. A large part of that job was helping seniors navigate  TennCare’s highly complex maze of rules.     While serving in this role, I saw TennCare engage in numerous questionable tactics, which were often aimed at reducing  the number of enrollees, preventing people from gaining initial eligibility, or limiting their access to services once  enrolled. For my home and community‐based services clients, TennCare would arbitrarily, and with no advance notice,  cap the amount of time an enrollee could get healthcare assistance at home, and even in cases where it was abundantly  clear that more, not less, assistance was needed. TennCare also structured its appeals process in a way that it is nearly  impossible for a non‐lawyer to navigate it successfully.     I have additionally assisted people who were erroneously kicked out of the Medicaid program. I would step in to help  them re‐demonstrate their eligibility to TennCare, and the issue would only be resolved after months of sending  paperwork and letters back and forth or attending a hearing. It brings me to tears when I think about the hundreds or  thousands of seniors who had experiences similar to my clients, but who lacked someone like me to advocate on their  behalf and make sure TennCare's errors were corrected.     The current Block Grant proposal goes squarely against the objectives of the Medicaid program because it gives the  state even wider latitude to cut vital health services for vulnerable individuals, most of whom do not have the strength  or capacity to mount an opposition to such actions. With the new proposal, the state could eliminate or restrict services  like physical therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets  them. The proposal could also cut back on core health care services like hospital care, without federal approval or public  notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight, or be exempt from maintaining compliance with federal standards, which are in  place for the protection of patients. Without such safeguards, the state could return to the days when managed care  contractors failed to provide care to patients and providers were left unpaid. This proposal invites fraud and abuse and  threatens the availability of vital health coverage for Tennesseans, and the elderly more so than any other group.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal. The state can find its monetary savings elsewhere –  taking it from the poor, vulnerable, and medically needy is not the answer.       22 Sincerely,  Jessica Stewart  Knoxville, TN 37923  jstewartlaw865@gmail.com  23 Jonathan Reeve From: Sent: To: Subject: arlyn.ende@everyactioncustom.com on behalf of Arlyn Ende-Hastings Wednesday, October 2, 2019 1:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am an 87 year old widow with a very small monthly Social Security check. Because of Social Security and Medicaid, and  the additional “extra help” discounts, I can still feel secure in seeing my doctor and getting my medications. All total, I’m  extremely grateful for the programs that exist to help me.     I am afraid the “Block Grant” proposal will adversely affect me and many seniors like me.     I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant”    I feel this proposal would cause immense harm and jeopardize coverage of vulnerable Tennesseans like myself. The  services I now receive simply cannot be subject to cuts that Tennessee authorities might make to core healthcare  services and arbitrarily limit who gets them.     I think TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight‐ or eliminate federal standards which are in place for the protection of patients.This  proposal invites fraud and abuse and threatens the availability of vital health coverage for Tennesseans.    Sincerely,     Arlyn Ende‐Hastings        This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Arlyn Ende‐Hastings  464 Wildwood Ln  Sewanee, TN 37375‐3016  arlyn.ende@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: jrwohlgemuth@everyactioncustom.com on behalf of jim wohlgemuth Wednesday, October 2, 2019 2:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans including veterans and their spouses.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. Unfortunately the Tennessee state legislature has shown that  it can not be trusted to take care of Tennesseans who do not fit their mold.  The state could eliminate or restrict services  like physical therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets  them. The proposal could also cut back on core health care services like hospital care, without federal approval or public  notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  jim wohlgemuth  800 Gloucester Ln  Nashville, TN 37221‐6623 jrwohlgemuth@juno.com  25 Jonathan Reeve From: Sent: To: Subject: anniecowherd@everyactioncustom.com on behalf of Annie Cowherd Wednesday, October 2, 2019 3:05 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Attention relating to TN Issue   Dear Gabe Roberts,    Good Afternoon:    After living in TN for over 30 years and fighting for those whom no one else seems to see or care about other than at  Election time.  The "block grant" program does nothing than hurt the most vulnerable amongst us.  If you are reading  this, please remember the man you work for has and will keep showing up, talking about God, which is not allowed in  the workplace.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  the essential health coverage they need. This proposal goes against the objectives of Medicaid because it gives  Tennessee new authority to cut services for these vulnerable populations. The state could eliminate or restrict services  like physical therapy, hospice, and transplant coverage without reasonable federal oversight – and arbitrarily limit who  gets them. The proposal could also cut back on core health care services like hospital care, without federal approval or  public notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients, and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.   Please help someone other than yourself while  you are on earth; it's the only real "legacy" you will ever have and or need.     Sincerely,  Annie Cowherd      Sincerely,  Ms. Annie Cowherd  5905 Stone Brook Dr  Brentwood, TN 37027‐3920 anniecowherd@gmail.com  26 Jonathan Reeve From: Sent: To: Subject: cmaland@everyactioncustom.com on behalf of Charles Maland Wednesday, October 2, 2019 3:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    All three voting members of our family are opposed to the proposal to  change Tennessee’s Medicaid partnership with  the federal government by converting federal funding for TennCare into a “block grant.”   We are opposed for several  reasons:    1. We believe that if the state is seriously interested in helping the health outcomes of Tennesseeans, the state should  expand Medicare, as many states (whose populations are healthier than Tennessee's are) have done for several years.   The block grant proposal either will cover fewer people a little better or more people much less effectively than is  currently the case.      2. The Affordable Care Act, which offers solid patient protections which would be not be included in the block grant  scheme, has saved the lives of many Tennesseeans who have gotten insurance from the Marketplace.  We have no  confidence in medical insurance that does not offer those patient protections, including rock solid protection for citizens  with pre‐existing conditions and mental health and substance abuse treatment for those who need it.      3. TennCare has always failed to generate broad enough coverage for all Tennesseans, and it has often thrown people  off the rolls when costs rise or the economy fails.  Just this year tens of thousands of kids were tossed off TennCare.   There's evidence right now that the economy is slowing and perhaps heading for a recession.  Why not expand Medicare  before that happens?    4. The Federal Government, if it follows current law, cannot approve this proposal.  The current task force and and  proposal seem to many of us just another stalling tactic to prevent the expansion of health coverage to Tennesseans.   It's already stalled expansion of health coverage nine months.    We're vigorously opposed to any plan that doesn't move in the direction of expanding Medicare and honoring the  patient protections of the Affordable Care Act.    We'd suggest that every legislator, the Governor, Mr. Roberts himself, and everyone who would be involved in  administering this block grant read Uwe Reinhardt's PRICED‐OUT, and answer the question that Dr. Reinhardt asks: Are  we comfortable with having a health care policy in the state (and the nation) that assures that only the wealthy get good  health care?   The three voters in our home are not comfortable with that, but that's what we've always had in  Tennessee.  Let's change it, and the block grant approach won't get the job done.           Sincerely,  Charles Maland  427 Oakhurst Dr  Knoxville, TN 37919‐6642 cmaland@utk.edu  27 Jonathan Reeve From: Sent: To: Subject: rkersey@everyactioncustom.com on behalf of Roy Kersey Wednesday, October 2, 2019 3:30 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Gov. Lee's Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. In addition, any attempt to restrict services only means that all Tennesseans end  up paying for the health care of those without any benefits in the form of higher overall healthcare expenses.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Roy Kersey  637 Mize Cir  Seymour, TN 37865‐3313  rkersey@tds.net  28 Jonathan Reeve From: Sent: To: Subject: jack31961@everyactioncustom.com on behalf of Jack Spencer Wednesday, October 2, 2019 7:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jack Spencer  303 Spoplar St Apt 205 Paris, TN 38242  jack31961@yahoo.com  29 Jonathan Reeve From: Sent: To: Subject: therapydirector@everyactioncustom.com on behalf of Jason Clopton Wednesday, October 2, 2019 7:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal   Dear Gabe Roberts,    There are so many children that we serve that need TNCare to receive therapies to help them gain skills and  independence in order to grow up to be productive individuals.  I am opposed to the proposal to radically change  Tennessee’s Medicaid partnership with the federal government by converting federal funding for TennCare into a “block  grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr Jason Clopton  1445 E 10th St  Cookeville, TN 38501‐2017 therapydirector@developmentaldelay.net  30 Jonathan Reeve From: Sent: To: Subject: heidicloptonpedsot@everyactioncustom.com on behalf of Heidi Clopton Wednesday, October 2, 2019 8:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am a pediatric occupational therapist serving hundreds of children.  TennCare has allowed so many precious ones to  receive therapeutic interventions to help them gain developmental skills that help them grow up to be productive  citizens.  I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Heidi Clopton  1445 E 10th St  Cookeville, TN 38501‐2017 heidicloptonpedsot@gmail.com  31 Jonathan Reeve From: Sent: To: Subject: kls020890@everyactioncustom.com on behalf of Kristen Smith Wednesday, October 2, 2019 8:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    This speaks to me personally as a mother of two children with disabilities who rely on TennCare for insurance coverage.  My son has Tay‐Sach’s, a neurodegenerative disease that will be fatal in the next couple of years and a daughter with  Autism. My son’s treatment costs will be large over the next couple of years as we navigate feeding tubes, breathing  issues, and ultimately in home end of life care. My daughter’s current therapies out of pocket would be $800+ a week.  These therapies are integral to improve her future quality of life and have already helped her to make huge progress in  her functionality. Please think about those who are covered under these proposed changes and how much they will  suffer.     Sincerely,  Kristen Smith  448 Macedonia Rd  Moss, TN 38575‐6525  kls020890@gmail.com  32 Jonathan Reeve From: Sent: To: Subject: rebeccas0479@everyactioncustom.com on behalf of Rebecca Sherfey Wednesday, October 2, 2019 9:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Rebecca Sherfey  195 Woodlawn Cir  Jonesborough, TN 37659‐3741 rebeccas0479@gmail.com  33 Jonathan Reeve From: Sent: To: Subject: cyusi@everyactioncustom.com on behalf of Charissa Yusi Wednesday, October 2, 2019 9:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am adamantly opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans.     Tennessee is still suffering from the fateful decision to not expand Medicaid. TN is leading the country in high rates of  rural hospital closures, infant mortality rates, and the number of uninsured children have gone up. These markers  should be red flags that our state needs more health coverage, not less!     Currently I am pursuing a masters in social work through UTK. When I started the program, I was impressed by  Tennessee's progressive and proactive approaches through Building Strong Brains and ACE's trainings (Adverse  Childhood Experiences). I was proud of the good work that my state is doing. However, this TennCare proposal is a huge  leap in the wrong direction. This reckless proposal will cut holes in the already precarious safety net for the poor and  vulnerable in Tennessee.     I am currently an intern now at an agency that works with low‐income families. One of my clients who certainly qualifies  for TennCare recently received a letter that her health insurance has ended since she did not turn in a bank statement.  The letter was dated August 1st and she received in at the end of September. TennCare needs accountability and a  better system for keeping eligible people on the rolls!    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Charissa Yusi  2400 Clifton Ave  Nashville, TN 37209‐4117 cyusi@fcsnashville.org  34 Jonathan Reeve From: Sent: To: Subject: gigisimone62@everyactioncustom.com on behalf of Gina Sims-Johnson Wednesday, October 2, 2019 9:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Gina Sims‐Johnson  Winchester, TN 37398  gigisimone62@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: bakamp@everyactioncustom.com on behalf of Byron Kamp Wednesday, October 2, 2019 9:32 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Byron Kamp  537 Scout Dr  Mount Juliet, TN 37122‐6169 bakamp@gmail.com  36 Jonathan Reeve From: Sent: To: Subject: cbswanso@everyactioncustom.com on behalf of Carol Swanson Wednesday, October 2, 2019 9:37 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Strongly OPPOSE Tennessee's Medicaid Block Grant Proposal   Dear Gabe Roberts,    My husband and I retired to Maryville, Tennessee, in 2015. We love living here, but are discouraged that the state lags  behind in healthcare (so many rural hospitals have closed!) and voter participation.     We want Tennessee to LEAD THE WAY in providing reasonable healthcare for all of its citizens. For that reason, we  strongly oppose to the proposal radically changing Tennessee’s Medicaid partnership with the federal government. Do  NOT convert federal funding for TennCare into a “block grant.” This proposal would jeopardize the well‐being of too  many vulnerable Tennesseans.     Giving Tennessee new authority to cut services for at‐risk populations is a huge mistake. The state could eliminate or  restrict services like physical therapy, hospice, and transplant coverage without normal federal oversight – and  arbitrarily limit who gets them. The proposal could also cut back on core health care services like hospital care, without  federal approval or public notice, and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. Do not return to the days when managed care contractors failed to  provide care to patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the  availability of vital health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Carol Swanson  2014 Oakwood Dr  Maryville, TN 37803‐6420 cbswanso@gmail.com  37 Jonathan Reeve From: Sent: To: Subject: mruss94@everyactioncustom.com on behalf of Mark Russell Wednesday, October 2, 2019 9:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mark Russell  1947 Carters Creek Pike  Franklin, TN 37064‐5912 mruss94@yahoo.com  38 Jonathan Reeve From: Sent: To: Subject: paige.sievers@everyactioncustom.com on behalf of Paige Sievers Wednesday, October 2, 2019 11:08 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Paige Sievers  2012 Raccoon Valley Rd  Powell, TN 37849‐7537 paige.sievers@yahoo.com  39 Jonathan Reeve From: Sent: To: Subject: cmw1146@everyactioncustom.com on behalf of Carl Wheeler Wednesday, October 2, 2019 5:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Carl Wheeler  2631 Bakertown Rd  Knoxville, TN 37931‐4908 cmw1146@gmail.com  40 Jonathan Reeve From: Sent: To: Subject: stopcoalcrimes@everyactioncustom.com on behalf of Bill McCabe Wednesday, October 2, 2019 6:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I live in the second poorest county in TN and spend a lot of time talking with neighbors and others in the county. I have been involved the last   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Bill McCabe  726 Clinch Mountain Rd  Eidson, TN 37731‐7420 stopcoalcrimes@gmail.com  41 Jonathan Reeve From: Sent: To: Subject: ashley.karpinos@everyactioncustom.com on behalf of Ashley Karpinos Tuesday, October 1, 2019 8:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I am a local Pediatrician and many of my patients rely on TennCare for access to vital health services they could  otherwise not afford. Some patients need complex care and absolutely will not get the life‐saving access to our state's  medical services unless they have TennCare in a form that does not restrict their access to the many needed services.  These children and and families are vulnerable at times of unexpected illness. We need to make sure out system is ready  to help and not let any child go without needed access to services.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Ashley Karpinos  Nashville, TN 37215  ashley.karpinos@vanderbilt.edu  42 Jonathan Reeve From: Sent: To: Subject: dgould4212866@everyactioncustom.com on behalf of Denis Gould Tuesday, October 1, 2019 9:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant's will only serve to cheat needy Tennesseans. l   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Denis Gould  1626 Kinder Ln  Dandridge, TN 37725‐6522 dgould4212866@yahoo.com  43 Jonathan Reeve From: Sent: To: Subject: saramatthewsholmes@everyactioncustom.com on behalf of Sara Holmes Tuesday, October 1, 2019 9:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I strongly oppose converting the current Tenn Care system to a Medicaid Block grant. Tennessee has thousands of residents whose medical needs are not covered now.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sara Holmes  193 Azalea Garden Way # WAY Memphis, TN 38111‐4756 saramatthewsholmes@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: jgriffin38368@everyactioncustom.com on behalf of Jeffrey Griffin Tuesday, October 1, 2019 9:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jeffrey Griffin  33100 Highway 104 S  Reagan, TN 38368‐6239 jgriffin38368@gmail.com  45 Jonathan Reeve From: Sent: To: Subject: jgriffin38368@everyactioncustom.com on behalf of Jeffrey Griffin Tuesday, October 1, 2019 9:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jeffrey Griffin  33100 Highway 104 S  Reagan, TN 38368‐6239 jgriffin38368@gmail.com  46 Jonathan Reeve From: Sent: To: Subject: nana@everyactioncustom.com on behalf of nancy young Tuesday, October 1, 2019 9:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block the block grant. It will not better help the health of Tenneseans. Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  nancy young  11 Burton Hills Blvd Apt 358 Nashville, TN 37215‐6151 nana@aol.com  47 Jonathan Reeve From: Sent: To: Subject: morgan.leigh.kane@everyactioncustom.com on behalf of Morgan Kane Tuesday, October 1, 2019 9:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     As a Pediatric Occupational Therapist at Vanderbilt University Medical Center, majority of the children I see are  dependent on the TennCare they receive. Not just for their doctor's appointments, medical imaging, and emergency  room visits, but also their weekly therapy services. I see children from all walks of life‐ babies with birth injuries that lose  movement and strength in their arms, children with developmental disabilities like spina bifida, cerebral palsy, and  Autism who have visual and motor deficits, and adolescents with cognitive impairments trying to make plans for after  high school. As an OT, it's my job to facilitate independence my clients every day routines. How can we build their hand  strength to hold a spoon? How can we educate on dressing techniques and equipment after a spinal fusion? How do we  improve their social participation with friends? How to we improve their handwriting legibility? Can they tell time, keep  track of their finances, and manage their health information? Everyday it is my goal, and the goal of my colleagues, to  have children walk out the door with a better quality of life. TennCare ensures good quality therapy is accessible to all. It  gives all children the opportunity to contribute to the world around them. Putting this insurance coverage at risk would  not just jeopardize the health care these children would receive, but it would ultimately minimize their ability to live life  to the fullest.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Morgan Kane  1001 4th Ave N Apt 217 Nashville, TN 37219‐1140 morgan.leigh.kane@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: debbygould@everyactioncustom.com on behalf of Debby and Gould Tuesday, October 1, 2019 9:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I strongly oppose the conversion of Tennessee's funding stream from the federal government into a Block Grant.  As  today's testimony  in Nashville made clear, the potential for great damage to the health care of Tennesseans is very, very  real. The proposal incentivizes the state to impose an extremely limited closed drug formulary and shortchanges the  essential measures of accountability to Tenncare that our patients need.      The uncomfortable truth for Tennessee is that spending cuts to healthcare almost always lead to poorer patient  outcomes rather than efficiencies in service.    This waiver goes against the goals and purpose of the Medicaid program. I urge you not to go forward with this harmful  proposal.    Sincerely,  Debby and Gould  1817 Beechwood Ave  Nashville, TN 37212‐5401 debbygould@bellsouth.net  49 Jonathan Reeve From: Sent: To: Subject: kpruiett64@everyactioncustom.com on behalf of Kathy Pruiett Tuesday, October 1, 2019 10:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathy Pruiett  95 King Arthur Dr  Paris, TN 38242‐7923  kpruiett64@yahoo.com  50 Jonathan Reeve From: Sent: To: Subject: 711kanderson@everyactioncustom.com on behalf of Kristen Anderson <711kanderson@everyactioncustom.com> Tuesday, October 1, 2019 11:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kristen Anderson  85 Utley Rd  Westport, TN 38387‐6228  711kanderson@gmail.com  51 Jonathan Reeve From: Sent: To: Subject: hfstaple@everyactioncustom.com on behalf of Helen Stapleton Tuesday, October 1, 2019 5:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Helen Stapleton  263 University Ave  Sewanee, TN 37375‐2259 hfstaple@yahoo.com  52 Jonathan Reeve From: Sent: To: Subject: Susan.lingerfelt@everyactioncustom.com on behalf of Susan Lingerfelt Tuesday, October 1, 2019 5:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    No you have screwed the little guy to death!  Of course you apparently don’t care!  I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Susan Lingerfelt  645 Sunview Dr  Athens, TN 37303‐4562  Susan.lingerfelt@gmail.com  53 Jonathan Reeve From: Sent: To: Subject: sheritylerkimble@everyactioncustom.com on behalf of Sheri Kimble Tuesday, October 1, 2019 5:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I am not on TennCare of Medicaid, but like most people, any catastrophe could put me there.  I am very concerned  about the lack of oversight or accountability presented in the block grant proposal.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed. It goes against the goals and purpose of the Medicaid program. I implore you not to  go forward with this harmful proposal. and ask them to present a more plausible and compassionate proposal.    Sincerely,  Sheri Kimble  148 41st Ave N  Nashville, TN 37209‐4770 sheritylerkimble@gmail.com  54 Jonathan Reeve From: Sent: To: Subject: lindsaykbishop@everyactioncustom.com on behalf of Lindsay Bishop Tuesday, October 1, 2019 5:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lindsay Bishop  629 Indian Ridge Dr  Nashville, TN 37221‐4035 lindsaykbishop@gmail.com  55 Jonathan Reeve From: Sent: To: Subject: dan.mceachern@everyactioncustom.com on behalf of Daniel McEachern Tuesday, October 1, 2019 6:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid (TennCare in Tennessee) is in danger of being turned over to a state where Republicans hold a super majority in the state legislature and a Republican Governor who will divert this money because there will be no restrictive oversite.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Daniel McEachern  2953 Franklin Pike  Nashville, TN 37204‐3423 dan.mceachern@comcast.net  56 Jonathan Reeve From: Sent: To: Subject: lesa.d.franklin@everyactioncustom.com on behalf of Lesa Franklin Tuesday, October 1, 2019 6:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Protect Our Most Vulnerable Citizens: NO Medicaid Block Grant   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lesa Franklin  Nashville, TN 37214  lesa.d.franklin@gmail.com  57 Jonathan Reeve From: Sent: To: Subject: ROSE Shelton Thursday, October 3, 2019 7:58 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposition to Tn Medicaid Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐      Sent from my iPad  59 Jonathan Reeve From: Sent: To: Subject: Cathy Pyron Thursday, October 3, 2019 5:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicare block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I think you need to be listening to the health care professionals on this issue. While the argument of decreasing  overhead expenses of TennCare by using block grants has appeal, the potential drawbacks seem to be outweighing this.  Rationing of healthcare, which is what this will inevitably lead to, is the actual “death panels” Governor Palin decried in  2008.   For the life of me, I do not understand why the government of Tennessee has been so obtusely stubborn about not  expanding Medicaid through the ACA. The crisis of hospital closures in Tennessee, with our state being number 1 per  capita with closures, along with our poor rating of healthcare outcomes overall,  is affecting us all, whether or not we  live in the small communities where the closures occur. Hospital closures are overburdening the rest of the hospitals,  with poor people bringing that same inability to pay with them. Rationing healthcare for the poor and disabled will not  improve this.   We need to be sensible and expand Medicaid through the ACA.     Cathy Pyron  Signal Mtn, TN  60 Jonathan Reeve From: Sent: To: Subject: Sally Carlson-Bancroft Thursday, October 3, 2019 5:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   This proposal appears to be a thinly veiled attempt by the state to obtain federal dollars without actually providing  health coverage to more people. How about studying successful Medicaid expansion programs in other states and  building on those, instead of using poor and low‐income Tennesseans as guinea pigs in some right wing attempt to do an  end run around the ACA?     Mark me down as NOT IN FAVOR.    Sally Carlson‐Bancroft   8421 Poplar Creek Rd  Nashville 37221  61 Jonathan Reeve From: Sent: To: Subject: Bonnie Holsinger Wednesday, October 2, 2019 8:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] block grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I'm against this block grant proposal and believe we should expand Medicaid under the Affordable Care Act. Both the US  government and Governor Lee think they can save money with the block grant. Those savings will have to come from  somewhere and it will from the medical care of Tennesseans, which is already inadequate.    You should have many more public meetings about this ‐ maybe one in each county.    Thank you,  Bonnie Holsinger  Summertown TN 38483  931‐255‐0881  bdholsinger@gmail.com  62 Jonathan Reeve From: Sent: To: Subject: debbiehunziker@everyactioncustom.com on behalf of Debbie Hunziker Wednesday, October 2, 2019 7:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Debbie Hunziker  297 Hunziker Rd  Tracy City, TN 37387‐0018 debbiehunziker@yahoo.com  63 Jonathan Reeve From: Sent: To: Subject: ROSE Shelton Wednesday, October 2, 2019 4:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposition to Block Grant Coverage     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐      Sent from my iPad  64 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of James Higdon Wednesday, October 2, 2019 3:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    The block grant does nothing to address the real health concerns of Tennesseans, and in fact, it would make things  worse.  This proposal would turn our current (already inadequate) program into something resembling private insurance  and is expected to have serious consequences for health care in Tennessee, affecting the most vulnerable children,  families and elderly residents.  The proposal would give Tennessee new authority to cut services for children, seniors,  low‐income parents, and people with disabilities. State leaders have said their goal is to take $2 billion OUT of  Tennessee's health care system.    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    James Higdon  1331 calderwood ave  Maryville, TN 37801‐4690   65 Jonathan Reeve From: Sent: To: Subject: Barbra Deck <67bdeck@gmail.com> Wednesday, October 2, 2019 3:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant for TennCare (Tennessee's Medicaid Program)   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern,  I do not support the "Block Grant" idea.  We need the federal government to provide funding not in the form of a block  grant but in a specific amount for our TennCare (Medicaid  Program).  One in ten Tennesseans does not have health insurance.  Our children (whether they be lower income or  rich) need health insurance.  Several of Tennessee's hospitals  in the rural areas have already closed.  No other state in the nation is using this block grant program.   Sincerely,  Barbra Deck  802 Boscobel St.  Nashville, TN 37206    66 Jonathan Reeve From: Sent: To: Subject: Jim Webster Wednesday, October 2, 2019 2:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I was told that Chattanooga has been added to the list of sites for public comments. Is this true? Can you provide details.  If it is not true, why are we left out?    Jim Webster, CTS‐D, ISF‐C  Continental Film  P.O. Box 5126  1466 Riverside Drive  Chattanooga, TN 37406  Tel: 423‐622‐1193  Fax: 423‐629‐0853  www.continentalfilm.com  jim.webster@continentalfilm.com     67 Jonathan Reeve From: Sent: To: Subject: Shetima Marie Baugh Wednesday, October 2, 2019 1:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid block grant comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   A block grant disbursed from Medicaid would not enable a recipient to seek adequate care. Limited funds equate to  limited care, or in some extreme cases, will force some not to seek medical care at all.  A block grant is restrictive,  placing restrictions on care due to costs. For example, if a medicaid recipient needs surgery as well as treatment  afterwards, they may have to forfeit the lifesaving procedure because of the allotment given to them through a block  grant.  With the closure of rural hospitals across the state, accessing care is increasingly difficult. Tennesseans will not benefit  from a medicaid block grant.  68 Jonathan Reeve From: Sent: To: Subject: Linda Fletcher Wednesday, October 2, 2019 11:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I oppose the block grant that is being proposed. This would critically affect thise citizens most vulnerable to the actions  of this block grant. Please be informed. Do not let this be pushed through.   Linda F Fletcher    Sent from my iPhone  69 Jonathan Reeve From: Sent: To: Subject: Don Carlin Wednesday, October 2, 2019 11:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenncare should be expanded not reduced     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  According to an article appearing in the Tennesseean last year (https://urldefense.proofpoint.com/v2/url?u=https‐ 3A__www.tennessean.com_story_money_2018_10_30_ut‐2Dstudy‐2Danother‐2D43‐2D000‐2Dtennesseans‐2Dnow‐ 2Duninsured_1813170002_&d=DwIFaQ&c=9mDSiW‐N7q3Jcc5YTFWHgQ&r=6OUlRdShDfdokB‐ fAB712GvEnidbNezxXl1avL74bik&m=V2zgU2gE0_6mSUwhC9aJ2WB7h6J8Vua3kKRF2i7dOhk&s=eDQ64kHOJwkCgtnqAGS rMFSBQ1Wnmjhhub6s6u9lTmA&e= ), 451,000 Tennesseans do not have health insurance, having grown 43,000 from  the previous year. And the number of uninsured Tennesseans continues to grow.     Gov Lee wants to turn Medicaid in Tennessee into a block grant. That’s a bad idea. If approved, even more Tennesseans  would lose their health insurance. The amount of funding Tennessee receives for Medicaid is flexible; it goes up as more  Tennesseans become eligible. Under a block grant, the amount of funding Tennessee receives from the federal  government is fixed. This is bad for two reasons. First, even more Tennesseans would lose their health coverage.  Secondly, and more importantly, the rules regarding how Medicaid funds are used are fairly rigid. Under a block grant,  the state would be potentially free to use these funds in ways that were never intended by the Centers for Medicare and  Medicaid Services. For example under a block grant, the administration could limit or restrict access to health care by  region, population, cap funding for treatment of certain illnesses.     Tennessee needs to do more to increase health care coverage for its citizens not force more people off the Tenncare  rolls. My brother‐in‐law is disabled and is on Tenncare. Tenncare has been a blessing for him. Without Tenncare and the  health care he receives, he would probably die.     Sincerely,    Don Carlin  Clarksville, Tennessee  70 Jonathan Reeve From: Sent: To: Subject: JAY LUCAS Wednesday, October 2, 2019 10:32 AM PUBLICE NOTICE TENNCARE [EXTERNAL] block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   After reading the grant proposal and listening to the public comments yesterday(10/1/19) I am more convinced than ever that the  block grant would do unbelievable harm to the children and elderly in Tennessee.   It is difficult for me to understand how Gov. Lee who ran for governor as a strong proponent of his Christian values can advocate for  this block grant. It will undoubtedly be a disadvantage the poor and disabled in TN who already are struggling.   Many of the comments I heard yesterday suggested expanding Medicaid which after much opposition has been accepted by 36  states.It becomes all to obvious that healthcare in TN is a political tool to insure votes and not a moral obligation to care for the less  fortunate.   In summation I want to express my strong oppostion to this block grant to healthcare in TN.  Thank you.  Ann Lucas  1736 Guill Rd.  Mount Juliet, TN 37122  615‐754‐9010  71 Jonathan Reeve From: Sent: To: Subject: Molly Nolte-Allen Wednesday, October 2, 2019 9:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Draft Waiver Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern:  I am writing in regards to the “draft waiver proposal” to convert TennCare into a “block grant.” I am highly against this  proposal.   As the mother of a 32‐year old son who is diagnosed with schizo‐affective disorder, this proposal would greatly affect  his quality of life. He is already mentally disabled; any further cuts on his insurance, including medication and  counseling, would be seriously detrimental to his well‐being. He struggles on a day‐to‐day basis mentally and  emotionally; any benefit downsizing would endanger his life.  As a tax‐paying, retired teacher, I highly encourage you to stop this measure.   Sincerely,  Molly Nolte‐Allen  Cleveland, TN  72 Jonathan Reeve From: Sent: To: Subject: Claiborne, Lily Lowery Wednesday, October 2, 2019 9:40 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Hello,    I write to covey my strong opposition to the block grant that is being proposed to replace federal Medicaid  administration.  We need to maintain ties to the larger funding mechanisms of the federal government, to allow  flexibility for folks who need more care over time.  We should not put this money in the hands of the TN state  government, which has overseen the closure of hospitals and failed to access available funds through Medicare  expansion, resulting in deaths of constituents who lost coverage.  Keep federal Medicaid in place – no block grant.  In a  civilized society like our own, healthcare is a right, not a privilege.    Thanks,    Lily Claiborne  Nashville, TN      73 Jonathan Reeve From: Sent: To: Subject: lynne Marchetti <833oak@gmail.com> Wednesday, October 2, 2019 8:26 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant vs. expanded Medicare coverage     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐      Although Gov. Lee touts greater state flexibility, loves the money from the Feds without strings, greater program  innovation is promised, we know GRANTS are highly vulnerable to federal budget cuts and generally leads to inequality  and divergent needs assessment from a basic standard of care.      This is simply a way for the Federal government to back away from Medicare and Medicaid putting 1,000,000’s at risk.   There are no guarantees from the Federal government that another block grant will follow with equal money and an  increase of funding as the population ages and healthcare costs continue to soar.      Stability of Medicare/Medicaid programs and expanded Medicaid is more wise.  This is simply too much of a gamble that  is all on the shoulders of the state’s people, which already pay taxes for these Block Grants to the Federal gov’t.  The  Federal government has made no promises that are worthy of an actual claim to more aid in the future based on higher  enrollment.  How does that actually work?    Considering how low the block grant funding is and how little services there are already invested in care levels for  medical and mental health care in the state of TN, saving money as a priority with the promise to fund more services  later all while not funding administration of the current programs through the proposed grant , well, the numbers just  don’t add up.  How will administration tighten the belt?      Essentially the federal government wants the state to do their work and pay for it with “less money through the block  grant.  The real reason this is happening is the influence from the federal government to remove thousands from the  rolls of federal government funded medicaid and medicare and put the burden on the state.  This is the end of “welfare”  as defined by the current federal administration who see the Medicaid and Medicare programs as a part of society’s ills  rather than seeing it as the ill that need these social programs.       Governors typically love block grants as it it gives them the credit for the appearance of bringing big money into the  state.  Nice for politics, not so nice for sick people.    The tendency in Congress has been to place more conditions on block grants with each annual appropriation.  Boot strap  economics for the poor and ill is a fantasy and does not help struggling families.  People do not dig their own way out of  oppressive life circumstances.  Oppression usually crushes people not uplift them.   Calling Medicare and Medicaid  “entitlements” and is Paul Ryan’s notion that he pushed hard to cut.  Now that he abandoned his post he can hardly be  held responsible for the loss of health care to millions.    Let’s be clear, the Republican agenda to cut taxes and having done so in 2017, are what is driving the deficit that is  driving the end of social services.  Tax cuts added $1 trillion to the deficit. The massive Republican tax cut could have  paid for Medicaid and Medicare but a tax break was given to you and now you want to take services away from average  Americans by taking our tax dollars and doming out less dollars for services saving the Feds money while short changing  the most needy.  Shame on you.  74   Social Security is on sound footing.  Leave it alone.  SS and Medicare benefit everyone not just poor.  SS is an essential social service.  Essential insurance.  I’ve seen Republicans use it and Democrats, old and young,  white,blue,pink collar‐ everyone.” at some point uses it or knows of loved ones needing it.  Leave it alone.                      75 Jonathan Reeve From: Sent: To: Subject: Flanagan Wednesday, October 2, 2019 7:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] re: Medicaid Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***     I am opposed to the Medcaid Tenncare Block Grant. My daughter was diagnosed with a chronic mental illness at the age  of 18, but had suffered since the age of 14 with it. It took 10 years of trying different medications and we had exhausted  them all except one final combination, which got her stabilized. If it were not for TennCare, we could not afford this  medication for her. Without this medication, she would go into crisis and end up in the hospital, which would cost much  more than her medication and she could possibly die. I plead that you don’t block TennCare to such needy individuals! If  it gets blocked, it would cost taxpayers and the government much more than if things were left inplace that are working.   Linda Flanagan  76 Jonathan Reeve From: Sent: To: Subject: Jenny Surratt Wednesday, October 2, 2019 6:22 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposed to TennCare Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good morning,  I want to inform you that I am opposed to the TennCare block grant proposal. Why would we want to cap federal  Medicaid funding in TN when we have no idea what the future holds. To do something that is so binding on the future  seems irresponsible and short term in thinking. There is a reason no other state has moved forward on the block grant.  TN should not be the guinea pig on such an important issue.    Thank you,  Jenny Surratt  77 Jonathan Reeve From: Sent: To: Subject: David Reeves Wednesday, October 2, 2019 4:35 AM PUBLICE NOTICE TENNCARE [EXTERNAL] block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   This proposal is untenable and destructive to those who most need help.  We are here to serve " the least of  these".  78 Jonathan Reeve From: Sent: To: Subject: Mary Jean Jewell Wednesday, October 2, 2019 12:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposition to Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   We are very concerned about health care for our uninsured family members:    1. Sister with chronic progressive multiple sclerosis ‐ private pay living in a nursing home, bedridden and legally blind.  Healthcare costs are exorbitant! Family members have stepped up to fund her care.    2. Brother with lung disease ‐ disabled. He is unable to pay medical bills but goes to the ER when he can’t breathe.  Hospitals do not turn him away even though they are not been reimbursed for his care.    Medicaid expansion (with federal oversight to provide safeguards for fair treatment) is preferable to a block grant  (without any guarantees for coverage).    Healthcare must be a HIGH priority ‐ regardless of a patient’s income and condition. Taking appropriate action to care  for ALL Tennesseans is long overdue.    Sincerely,    Bill and Mary Jean Jewell  4005 Brookhaven Drive  Nashville, TN 37204        ‐‐   Mary Jean Jewell  jewell.mary@gmail.com  615‐385‐2931  79 Jonathan Reeve From: Sent: To: Subject: Chris Goad Tuesday, October 1, 2019 10:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐    I do not think this method will be the best solution for Tennessee residence. Many people will not benefit and it could  be devastating for some.  Please do not go with the block grant.     Lillian C Goad  301 Freda Villa  Madison, Tn 37115        Sent from my iPhone  80 Jonathan Reeve From: Sent: To: Subject: janet@shouse.com Tuesday, October 1, 2019 10:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Re: Block grant proposal deeply troubling *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. *** Resending with contact information. On 2019-10-01 10:05 pm, janet@shouse.com wrote: Dear Mr. Roberts, I am deeply concerned about the threat that the Medicaid block grant proposal poses to people with disabilities in our state. I'm also concerned about other populations served by TennCare as well, but as the parent of a young adult with autism and an intellectual disability, individuals with disabilities are the ones that I worry the most about.  There are currently about 7,000 people with intellectual and developmental disabilities on the "referral list" for the Employment and Community First CHOICES waiver program. Yet ECF CHOICES is included in the block grant. Block grant funding will make it harder to expand services or serve additional people. So what happens to those 7,000 and the growing numbers of individuals with autism? Our state's autism prevalence rate THIS YEAR is 1 in 64 8-year-olds. Many of those children will need access to long-term supports and services, particularly when they reach adulthood. The state has not been overly generous in adding more funding to address the referral list over the years and without the federal match the situation will only become worse.  I realize that the proposal "carves out" the three waivers administered by the Department of Intellectual and Development Disabilities, but this does not address the individuals on the current "referral list," and that individuals with intellectual disabilities in DIDD services will still be impacted by any changes to health services.  While the new Katie Beckett Program will not be included in the block grant for the first three years of operation, after that time, the funding needed for operations (whether or not enrollment is at full capacity) will be through the block grant. Again, block grant funding will make it hard to expand services or serve additional children.  Tennessee is asking to be exempt from future federal Medicaid mandates. This means that if the federal government mandated that states cover a particular medication or provide a new type of service, Tennessee would be exempt from that rule and not have to do so. This is likely to hurt people with disabilities in particular. Changes to the Early Prevention, Screening, Diagnosis and Treatment mandate are just one example.  Tennessee is currently required to cover all prescription medications included in the federal Medicaid drug rebate program. The move to a commercial-style closed prescription drug formulary, 81 as you are well aware, could limit prescriptions covered, in particular specialty medications needed by a small group of people, again, particularly for those with disabilities. For example, people who are dually diagnosed with an intellectual or developmental disability and a mental illness do not always respond in the same way to the drugs used to treat many common mental illnesses. It often requires a great deal of trial and error with many medications, and the consequence of not finding the "right" medication often means very significant behavior challenges that will only increase costs to the system over time. And the idea of having one drug available for a particular condition would be disastrous for this population. My son has already been treated with and failed with five atypical antipsychotic medications, and he's now on his sixth.  The federal Medicaid comparability requirement means that covered benefits must be the same for all covered populations. Tennessee is asking to waive this requirement, which would allow TennCare to vary the types of benefits that are available to different types of patients. This request is truly terrifying. This could prevent an individual beneficiary from accessing the types of services he or she needs. Historically, people with disabilities have been a lower priority than other populations and have been adversely affected by cuts to services.  Tennessee is asking to never have to reapply or have TennCare re-evaluated by the federal government. This would remove oversight of the program. Federal oversight has traditionally been critical to protecting people with disabilities. I have seen over and over how critical federal oversight is in the educational realm, through the Individuals with Disabilities Education Act. Tennessee's own Arlington and Clover Bottom lawsuits regarding institutionalization had federal monitoring until the suits were settled, in order to ensure the protection of the rights of people with disabilities. Please don't jettison these protections!  Tennessee is asking to be able to make changes to the benefits it provides, TennCare enrollment processes and service delivery systems without federal government approval or oversight. Again, federal oversight has traditionally been critical to protecting people with disabilities. Can you understand how difficult it is for families like mine to hear our state brag about how much money Tennessee has saved with TennCare over the years, but yet for nearly 20 years there have been 6,0007,000 people with intellectual or developmental disabilities waiting for needed services? (Our son was on the waiting list for 11 years.) Was that right? Nationally, about 25% of individuals with intellectual and developmental disabilities receive home- and community-based services through their states' Medicaid waivers. The average in Tennessee is about 7%. Is that right? I talk with families of children and adults with significant disabilities nearly every day who cannot get the appropriate supports and services, even though they are on TennCare or on Employment and Community First CHOICES. Is that the way it's supposed to be? You and our state legislators have asked the people of Tennessee to trust you to do what's right for Tennesseans. Do you understand why we in the disability community have deep concerns that this proposal will disproportionately negatively affect those with disabilities? I would ask that, if possible, the waiver amendment proposal to block grant Medicaid not be sent to the Centers for Medicare and Medicaid Services. Thank you. Janet Shouse 409 Crofton Park Lane Franklin, TN 37069 615-202-5259 82 Jonathan Reeve From: Sent: To: Subject: janet@shouse.com Tuesday, October 1, 2019 10:06 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant proposal deeply troubling *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. *** Dear Mr. Roberts, I am deeply concerned about the threat that the Medicaid block grant proposal poses to people with disabilities in our state. I'm also concerned about other populations served by TennCare as well, but as the parent of a young adult with autism and an intellectual disability, individuals with disabilities are the ones that I worry the most about.  There are currently about 7,000 people with intellectual and developmental disabilities on the "referral list" for the Employment and Community First CHOICES waiver program. Yet ECF CHOICES is included in the block grant. Block grant funding will make it harder to expand services or serve additional people. So what happens to those 7,000 and the growing numbers of individuals with autism? Our state's autism prevalence rate THIS YEAR is 1 in 64 8-year-olds. Many of those children will need access to long-term supports and services, particularly when they reach adulthood. The state has not been overly generous in adding more funding to address the referral list over the years and without the federal match the situation will only become worse.  I realize that the proposal "carves out" the three waivers administered by the Department of Intellectual and Development Disabilities, but this does not address the individuals on the current "referral list," and that individuals with intellectual disabilities in DIDD services will still be impacted by any changes to health services.  While the new Katie Beckett Program will not be included in the block grant for the first three years of operation, after that time, the funding needed for operations (whether or not enrollment is at full capacity) will be through the block grant. Again, block grant funding will make it hard to expand services or serve additional children.  Tennessee is asking to be exempt from future federal Medicaid mandates. This means that if the federal government mandated that states cover a particular medication or provide a new type of service, Tennessee would be exempt from that rule and not have to do so. This is likely to hurt people with disabilities in particular. Changes to the Early Prevention, Screening, Diagnosis and Treatment mandate are just one example.  Tennessee is currently required to cover all prescription medications included in the federal Medicaid drug rebate program. The move to a commercial-style closed prescription drug formulary, as you are well aware, could limit prescriptions covered, in particular specialty medications needed by a small group of people, again, particularly for those with disabilities. For example, people who are dually diagnosed with an intellectual or developmental disability and a mental illness do not always respond in the same way to the drugs used to treat many common mental illnesses. It often requires a great deal of trial and error with many medications, and the consequence of not finding the "right" medication often means very significant behavior challenges that will only increase costs to the system over time. And the idea of having one drug available for a particular condition would be disastrous for this population. My son has already been treated with and failed with five atypical antipsychotic medications, and he's now on his sixth. 83  The federal Medicaid comparability requirement means that covered benefits must be the same for all covered populations. Tennessee is asking to waive this requirement, which would allow TennCare to vary the types of benefits that are available to different types of patients. This request is truly terrifying. This could prevent an individual beneficiary from accessing the types of services he or she needs. Historically, people with disabilities have been a lower priority than other populations and have been adversely affected by cuts to services.  Tennessee is asking to never have to reapply or have TennCare re-evaluated by the federal government. This would remove oversight of the program. Federal oversight has traditionally been critical to protecting people with disabilities. I have seen over and over how critical federal oversight is in the educational realm, through the Individuals with Disabilities Education Act. Tennessee's own Arlington and Clover Bottom lawsuits regarding institutionalization had federal monitoring until the suits were settled, in order to ensure the protection of the rights of people with disabilities. Please don't jettison these protections!  Tennessee is asking to be able to make changes to the benefits it provides, TennCare enrollment processes and service delivery systems without federal government approval or oversight. Again, federal oversight has traditionally been critical to protecting people with disabilities. Can you understand how difficult it is for families like mine to hear our state brag about how much money Tennessee has saved with TennCare over the years, but yet for nearly 20 years there have been 6,0007,000 people with intellectual or developmental disabilities waiting for needed services? (Our son was on the waiting list for 11 years.) Was that right? Nationally, about 25% of individuals with intellectual and developmental disabilities receive home- and community-based services through their states' Medicaid waivers. The average in Tennessee is about 7%. Is that right? I talk with families of children and adults with significant disabilities nearly every day who cannot get the appropriate supports and services, even though they are on TennCare or on Employment and Community First CHOICES. Is that the way it's supposed to be? You and our state legislators have asked the people of Tennessee to trust you to do what's right for Tennesseans. Do you understand why we in the disability community have deep concerns that this proposal will disproportionately negatively affect those with disabilities? I would ask that, if possible, the waiver amendment proposal to block grant Medicaid not be sent to the Centers for Medicare and Medicaid Services. Thank you. 84 Jonathan Reeve From: Sent: To: Subject: joyce russell Tuesday, October 1, 2019 8:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I OPPOSE Tenn Care block grant.    Joyce Russell  1308 Knightsbridge  Drive  Knoxville, TN 37922   86 Jonathan Reeve From: Sent: To: Subject: Carol Tures Tuesday, October 1, 2019 7:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Yes, I would like to see the grant proposal "blocked!"  I attended the open hearing today in Nashville and heard about all  the angles.  Only the first speaker for TennCare spoke in favor of the block grant.  No one else in the room stood up for  it.   It was very clear that the block grant would be a giant step backward for healthcare in Tennessee.  It was pointed out  today that Tennessee is not doing a very good job covering all those who need health care. children, the elderly, those  with unusual conditions, persons addicted to opiates, persons with mental illness.  As U.S. House Representative Jim  Cooper said, Tennessee is about the worst state for health care, and now we are trying to experiment with the health  program for those poor in our state and ignoring the needs of so many who cannot afford health insurance.    Sincerely,  Carol Tures  .      Carol Tures  405 Shackleford Court  Nashville, TN  37215    email:  caroltures@gmail.com  phone:  1‐615‐383‐1375  87 Jonathan Reeve From: Sent: To: Subject: Priscilla Jordan Tuesday, October 1, 2019 6:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Tennessee should just extend Obamacare Medicaid. This block grant deal is just foolish business. PRISCILLA JORDAN 88 Jonathan Reeve From: Sent: To: Subject: Tami Tallent Tuesday, October 1, 2019 5:51 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Oppose TennCare Block   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I depend on TennCare for my son’s medical needs. It’s extremely hard to get all the help we need. Please don’t take this  aid away from him and others.  What if this was your child that needed this help?  Please help us!  Thanks for your time.  89 Jonathan Reeve From: Sent: To: Subject: jasonferrell2004@everyactioncustom.com on behalf of Jason Ferrell Tuesday, October 1, 2019 12:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jason Ferrell  4108 Albert Dr  Nashville, TN 37204‐4204 jasonferrell2004@yahoo.com  90 Jonathan Reeve From: Sent: To: Subject: aflores09@everyactioncustom.com on behalf of Andrea Burroughs Tuesday, October 1, 2019 12:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As a health care provider in training, I am opposed to the proposal to change Tennessee’s Medicaid partnership with the  federal government by converting federal funding for TennCare into a “block grant.” This proposal would cause  immense harm and jeopardize coverage for my most vulnerable patients.      Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Andrea Burroughs  7109 Commonwealth Cir  Nashville, TN 37221‐6524 aflores09@email.mmc.edu  91 Jonathan Reeve From: Sent: To: Subject: natalierb12000@everyactioncustom.com on behalf of Natalie Baggett Tuesday, October 1, 2019 12:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Natalie Baggett  1020 Paint Pony Trl  Pegram, TN 37143‐5036 natalierb12000@yahoo.com  92 Jonathan Reeve From: Sent: To: Subject: kay.norman@everyactioncustom.com on behalf of Kay Norman Tuesday, October 1, 2019 12:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I am opposed to the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Kay Norman  5958 Manchester Pike  Murfreesboro, TN 37127‐7811 kay.norman@comcast.net  93 Jonathan Reeve From: Sent: To: Subject: surface@everyactioncustom.com on behalf of Elizabeth Surface Tuesday, October 1, 2019 12:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Elizabeth Surface  300 Harvard Ave  Nashville, TN 37205‐2334 surface@rossbryan.com  94 Jonathan Reeve From: Sent: To: Subject: shelita.morris@everyactioncustom.com on behalf of Shelita McIntosh Tuesday, October 1, 2019 12:37 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the Medicaid block grant proposal. I have friends and family who are very sick that depend on funding. They struggle enough, please don’t take this away.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Shelita McIntosh  Clarksville, TN 37042  shelita.morris@gmail.com  95 Jonathan Reeve From: Sent: To: Subject: cdleman@everyactioncustom.com on behalf of DiAnn Leman Tuesday, October 1, 2019 1:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I OPPOSE the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  DiAnn Leman  456 County Road 319  Niota, TN 37826‐3015 cdleman@gmail.com  96 Jonathan Reeve From: Sent: To: Subject: carbajo@everyactioncustom.com on behalf of Elisa Carbajo Tuesday, October 1, 2019 3:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Elisa Carbajo  Johnson City, TN 37604  carbajo@goldmail.etsu.edu  97 Jonathan Reeve From: Sent: To: Subject: doctorhurricane@everyactioncustom.com on behalf of Katrina Green Tuesday, October 1, 2019 1:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] This Physician Opposes the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Katrina Green  407 Bushnell St  Nashville, TN 37206‐1820 doctorhurricane@gmail.com  98 Jonathan Reeve From: Sent: To: Subject: sdpuckett21@everyactioncustom.com on behalf of Steven Puckett Tuesday, October 1, 2019 8:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” I'm opposed to this change on two grounds. The first is that  this the most pro‐abortion policy ever proposed by the state. The second is that this proposal would cause immense  harm and jeopardize coverage for vulnerable Tennesseans by making an already complicated system even more  complicated increasing the likely for failure to serve those intended to receive service.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs. In fact, Tennessee is currently under federal review for failure to  process applications for Tenncare in a timely manner and "mistakenly" cut children from the program. Further,  Tennessee's "efficiencies" haven't improved health outcomes as the program is intended to do. This signals that  Tennessee's "efficiencies" are due to mismanagement and improper denial of quality care. In fact, quality doctors have  been rejecting Medicaid due to the excessively low reimbursements. I fully expect this change to worsen the situation  and worsen health outcomes. Further, I expect that this change will drive more women to towards abortion given that  the change will eliminate the guarantee that coverage will be provided for their pregnancy costs as opposed to current  situation where the uncertainty is on when the costs will be paid.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans. Further, this proposal incentives the denial of care as the state Tennessee could use  denial of care as a means to use federal dollars intended for the provision of care to balance the budget by using  fraudulent "efficiencies" to "milk" the program of tax dollars.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful pro‐abortion proposal.    Sincerely,  Mr. Steven Puckett  228 Sanders Ferry Rd Apt A21 Hendersonville, TN 37075‐5100 sdpuckett21@students.tntech.edu  99 Jonathan Reeve From: Sent: To: Subject: jonicochran@everyactioncustom.com on behalf of Joni Cochran Tuesday, October 1, 2019 7:04 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Joni Cochran  401 S Mount Juliet Rd  Mount Juliet, TN 37122‐6359 jonicochran@gmail.com  100 Jonathan Reeve From: Sent: To: Subject: sherrycompton8@everyactioncustom.com on behalf of Sherry Compton Tuesday, October 1, 2019 8:06 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Sherry Compton  5021 Coro Rd  Memphis, TN 38109‐6124  sherrycompton8@gmail.com  101 Jonathan Reeve From: Sent: To: Subject: rlbml@everyactioncustom.com on behalf of Lorraine Barker Tuesday, October 1, 2019 9:00 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lorraine Barker  Nashville, TN 37204  rlbml@aol.com  102 Jonathan Reeve From: Sent: To: Subject: marnyy@everyactioncustom.com on behalf of MARNY Yenzer Tuesday, October 1, 2019 9:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Vote No to Block Grantsi   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  MARNY Yenzer  Brentwood, TN 37027  marnyy@hotmail.com  103 Jonathan Reeve From: Sent: To: Subject: cseador@everyactioncustom.com on behalf of Carol Seador Tuesday, October 1, 2019 10:06 AM PUBLICE NOTICE TENNCARE [EXTERNAL] NO to Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Carol Seador  Brentwood, TN 37027  cseador@yahoo.com  104 Jonathan Reeve From: Sent: To: Subject: csmithburwell@everyactioncustom.com on behalf of Constance Smith-Burwell Tuesday, October 1, 2019 10:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Constance Smith‐Burwell  112 Castlegate Cir  Nashville, TN 37217‐4208 csmithburwell@comcast.net  105 Jonathan Reeve From: Sent: To: Subject: topnotch48@everyactioncustom.com on behalf of Jeff ward Tuesday, October 1, 2019 10:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jeff ward  Jonesborough, TN 37659  topnotch48@aol.com  106 Jonathan Reeve From: Sent: To: Subject: kdrinkard1990@everyactioncustom.com on behalf of Kerianne Drinkard Tuesday, October 1, 2019 10:36 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Don't gut Tenncare! Shame on TN!!!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Kerianne Drinkard  Huntingdon, TN 38344  kdrinkard1990@gmail.com  107 Jonathan Reeve From: Sent: To: Subject: janet.carroll@everyactioncustom.com on behalf of Janet Carroll Tuesday, October 1, 2019 10:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Janet Carroll  Linden, TN 37096  janet.carroll@perrymedcenter.org  108 Jonathan Reeve From: Sent: To: Subject: watersdrpatricia@everyactioncustom.com on behalf of Patricia Waters Tuesday, October 1, 2019 10:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the Governor's undermining of Medicaid by establishing block grants.  Block grants corrupt the very purpose of Medicaid: to serve the underserved. Furthermore, people will die if Medicaid is  not expanded:     I am now quoting from a story on National Public Radio this morning, Oct 1: "A recent University of Michigan study  found Medicaid expansion substantially reduced mortality rates from 2014 to 2017. The researchers said Illinois averted  345 deaths annually while Missouri had 194 additional deaths each year. The same trends held for other side‐by‐side  states such as Kentucky (did expand) and Tennessee (did not), New Mexico (did) and Texas (did not)."    The Governor should not be allowed to make changes to the Medicaid program without federal oversight or eliminate  federal standards, which are in place for the protection of patients. Without such guardrails, the state could return to  the days when managed care contractors failed to provide care to patients and providers were left unpaid. This proposal  invites fraud and abuse and threatens the vital health care for Tennesseans.    If people are sick, they can't work. If they can't work, they can't pay their bills and certainly cannot pay taxes. They  cannot take care of their families nor contribute to their communities. The ripple effects of denying adequate health  care to those who can least afford to lose their livelihood will be enormous: hospital closures, medical bankruptcies,  families living in poverty.     This waiver is fundamentally flawed. It cannot be fixed. It corrupts the goals, the very purpose of the Medicaid program.  Respectfully, I ask that you not support this disaster in the making.  Regards, Dr. Patricia Waters   409 Lynn Ave. Athens, TN 37303    Sincerely,  Dr. Patricia Waters  409 Lynn Ave  Athens, TN 37303‐3719  watersdrpatricia@gmail.com  109 Jonathan Reeve From: Sent: To: Subject: meg.j.morton@everyactioncustom.com on behalf of Megan Morton Tuesday, October 1, 2019 11:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     I have a father who utilized Medicaid during a medical crisis and it saved his life. These programs are not intended to be  fitted to make solvent other state programs, they are meant to provide access to healthcare for vulnerable groups.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of the most effective prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Miss Megan Morton  Nashville, TN 37206  meg.j.morton@gmail.com  110 Jonathan Reeve From: Sent: To: Subject: terryjo.bichell@everyactioncustom.com on behalf of Terry Jo Bichell Tuesday, October 1, 2019 11:23 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment AGAINST Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am the Rare Disease Ambassador for the State of Tennessee, for the Rare Action Network of the National Organization  of Rare Disorders. I represent approximately 600,000 Tennesseans who suffer from one of the 7000 rare diseases. I am  also the mother of a 20 year old son with a rare genetic disease, Angelman syndrome. Recently, more and more rare  diseases are diagnosed through genetic testing and genome sequencing, and these lead to possible treatments, even  cures, for severe disorders.    People with rare diseases access the health care system and have a heavy need for medications and services, and many  of them are impoverished by the costs of medical care, eventually becoming dependent on the Medicaid system.    I am completely opposed to the proposal to “block grant” proposal. I can only believe that the designers of the bill do  not understand the new kinds of genetic treatments that are approaching the clinical trial phases. These treatments will  revolutionize the lives of patients, perhaps saving the state much money over time in welfare support and housing  support, but the drugs themselves can be very expensive. Forming a "block grant" at this time of intense  pharmacological innovation will cause the state to choose to either 1)go bankrupt by refusing the federal funds that  could pay for these drugs, or 2)cause harm and death to Tennessee children who will need these expensive drugs.    Please, help Tennesseans by rejecting the block grant proposal.    Sincerely,  Dr. Terry Jo Bichell  1510 Old Hickory Blvd  Brentwood, TN 37027‐4009 terryjo.bichell@rareaction.org  111 Jonathan Reeve From: Sent: To: Subject: tstarling@everyactioncustom.com on behalf of Tom Starling Tuesday, October 1, 2019 4:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Comment     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    This block grant proposal places flexibility and the "potential" savings over the medical care and access of vulnerable  populations. Today I talked to a mother, father, senior citizen, pastor, three doctors, and three trade associations, and  100% were against the block grant, as written.  Ultimately, the restrictions on the prescription drug formulary, the lack  of oversight, and the lack of details in the proposal are just unacceptable.  I so appreciate all that legislators have tried to  do, but I strongly urge Tennessee to not cap Medicaid with a block grant.    Sincerely,  Dr. Tom Starling  446 Metroplex Dr # A‐224 Nashville, TN 37211‐3186 tstarling@mhamidsouth.org  112 Jonathan Reeve From: Sent: To: Subject: Nancy Neilsen Tuesday, October 1, 2019 2:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   As the parent of an adult son with schizophrenia I am very much opposed to the Republican supported block grants.    It is hard enough advocating for my son who cannot do that successfully on his own with the present system. Keeping  him on his medication keeps him from being homeless and the Block Grants allow little oversight or standards that  ensure things will not change!!     Our state needs Medicaid expansion. So many of the rural hospital closures,for instance,  have been in the Southeast in  red states. I simply cannot fathom how people call themselves Christians and don't take care of the weakest among us.    Nancy R Neilsen   108 S Magnolia St   Maryville TN 37803  Sent from Yahoo Mail on Android  1 Jonathan Reeve From: Sent: To: Subject: ALLISON SIMONTON Tuesday, October 1, 2019 2:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] opposition to Medicaid block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   This letter is in opposition to Gov. Lee's block grant proposal.   The best analyses of this proposal report that the block grant will end up cutting Medicaid funds to Tennessee.   I am in favor of Medicaid expansion, not Medicaid shrinkage. Why would this state want to turn down Medicaid expansion except out of meanness towards the people with the least ability to pay for Medicaid? Thank you. Allison Jones 1640 Linden Ave. Memphis, TN 38104 2 Jonathan Reeve From: Sent: To: Subject: sharon smith Tuesday, October 1, 2019 12:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] re TennCare Block Grant Plan   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please   The only ethical, moral, right thing to do is to expand Medicaid coverage. Should the Block Grant Proposal go through,  all funds should be devoted to actual health care; nothing diverted off to any other bucket.     Regards,  Sharon Smith  1325 5th Avenue North   Nashville  37208  3 Jonathan Reeve From: Sent: To: Subject: chase.clemons@everyactioncustom.com on behalf of Chase Clemons Monday, September 30, 2019 8:02 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Chase Clemons  Fayetteville, TN 37334  chase.clemons@gmail.com  4 Jonathan Reeve From: Sent: To: Subject: robinkw@everyactioncustom.com on behalf of Robin K.Woodruff Monday, September 30, 2019 8:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    The evidence is out: expanded Medicaid works. I already let you know how as a disabled person , taking TennCare away  as a supplement to Medicare has not only affected me, but the financial burden has fallen others such as my elderly,  retired father you has stepped up to help pay the 20% not covered by Medicare. But also TN’s failure to expand  Medicaid and provide greater access to TennCare has hurt EVERYONE because doctors and hospitals are getting paid  less both to sequestration and patients who lack of coverage. Hospitals are shutting down and doctors are fleeing the  state. I personally have had 4 doctors leave in the past 5 months! So if not for moral and compassionate reasons, you  should oppose this block grant for selfish reasons because the domino effects of reducing TennCare further through the  back door method of a block grant will inevitably hurt you, your friend , and family ultimately as well!   But if you don’t believe me, read the research at https://urldefense.proofpoint.com/v2/url?u=https‐ 3A__www.washingtonpost.com_health_i‐2Dwould‐2Dbe‐2Ddead‐2Dor‐2Di‐2Dwould‐2Dbe‐2Dfinancially‐ 2Druined_2019_09_29_e697149c‐2Dc80e‐2D11e9‐2Dbe05‐2Df76ac4ec618c‐5Fstory.html‐3Fwpisrc‐3Dal‐5Fhealth‐5F‐ 5Falert‐2Dhse‐26wpmk‐3D1&d=DwIFaQ&c=9mDSiW‐N7q3Jcc5YTFWHgQ&r=6OUlRdShDfdokB‐ fAB712GvEnidbNezxXl1avL74bik&m=bsP‐ 4WeGJsYqvDHttV8vVcffF908OmS6_E5Q1BAZjH0&s=kUu50FxWBXAcPVEQ7OLTWp4LAOSd‐3TSeuhGR2GK2Mg&e=  As you can see, the evidence is clear: we need to benefit from the same results as those states who have expanded  Medicaid and not go backwards by reducing accountability of TennCare and eliminating access to thousands whose lives  depend on it!    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Robin K. Woodruff  5 6529 Deane Hill Dr Apt 41 Knoxville, TN 37919‐6011 robinkw@comcast.net  6 Jonathan Reeve From: Sent: To: Subject: jrkx2@everyactioncustom.com on behalf of Janet Knight Monday, September 30, 2019 8:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal..    I believe this is simply another Koch‐funded, among others, effort to protect the money of the wealthy with no concern  for people whose low‐paying daily jobs can’t support the high cost of medical care beyond anything but a sore throat, a  rash, or other simple medical issues. This is simply immoral and not what th    Sincerely,  Janet Knight  2129 Emery Ln  Franklin, TN 37064‐8926  jrkx2@comcast.net  7 Jonathan Reeve From: Sent: To: Subject: lindasherman1910@everyactioncustom.com on behalf of Linda Sherman Monday, September 30, 2019 8:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.”  Tennessee is willing to partner with the federal  government only on its own terms.  We do not need the problems which a new program would engender.  Look at the  states who have accepted Medicaid Expansion and see how well that is working.  Reinventing the wheel to offset the  enbarrassment of not having expanded Medicaid is inefficient and ineffective.      Where will the "savings" to TN taxpayers come from?  Perhaps in the 'small print' that only drugs of a certain class will  be used for a diagnosis, without regard to an individual's needs?  This is a medical red flag for failure with high prospects  of litigation.  The physician in our family could never agree to this kind of prescribing guideline.      This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  Why not revisit Medicaid Expansion and "save  money" for TN that is ours for the taking, and provide better care for those who most need help in our state.   "Pride  goeth before the fall."     Sincerely,    Linda Sherman, Brentwood, TN    Sincerely,  Linda Sherman  9429 Coxboro Dr  Brentwood, TN 37027‐8709 lindasherman1910@gmail.com  8 Jonathan Reeve From: Sent: To: Subject: missyk45@everyactioncustom.com on behalf of Sandra Scott Monday, September 30, 2019 8:42 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sandra Scott  712 Coggin Pass  Madison, TN 37115‐5416  missyk45@gmail.com  9 Jonathan Reeve From: Sent: To: Subject: colchamber@everyactioncustom.com on behalf of Colette Chambers Monday, September 30, 2019 8:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] OPPOSE   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Colette Chambers  Franklin, TN 37069  colchamber@comcast.net  10 Jonathan Reeve From: Sent: To: Subject: adg451@everyactioncustom.com on behalf of Art Gillen Monday, September 30, 2019 9:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I oppose the TennCare Block Grant - Look at how the State mismanaged oversight of the Ballad Health COPA   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. The management of the Ballad Health COPA is clear example of the State's  inability to fulfill its health care oversight commitments.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Art Gillen  7545 Cedar Creek Rd  Greeneville, TN 37743‐8248 adg451@gmail.com  11 Jonathan Reeve From: Sent: To: Subject: nqtucker@everyactioncustom.com on behalf of Naqwanda Tucker Monday, September 30, 2019 9:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Naqwanda Tucker  Goodlettsville, TN 37072  nqtucker@gmail.com  12 Jonathan Reeve From: Sent: To: Subject: baowens@everyactioncustom.com on behalf of Barbara Owens Monday, September 30, 2019 9:15 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Barbara Owens  300 Ridgetop Ct  Franklin, TN 37067‐4006 baowens@bellsouth.net  13 Jonathan Reeve From: Sent: To: Subject: bonita_mathis@everyactioncustom.com on behalf of Bonita Mathis Monday, September 30, 2019 9:37 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I am Opposed to the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Please d     Sincerely,  Bonita Mathis  841 W James M Campbell Blvd  Columbia, TN 38401‐4668 bonita_mathis@lcca.com  14 Jonathan Reeve From: Sent: To: Subject: rob.watkins@everyactioncustom.com on behalf of Rob Watkns Monday, September 30, 2019 9:38 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Rob Watkns  9038 Lochmere Ct  Brentwood, TN 37027‐2614 rob.watkins@comcast.net  15 Jonathan Reeve From: Sent: To: Subject: sales@everyactioncustom.com on behalf of Karen Tate Monday, September 30, 2019 9:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Karen Tate  6823 Sawyer Rd  Signal Mountain, TN 37377‐1375 sales@watergarden.com  16 Jonathan Reeve From: Sent: To: Subject: keyws1@everyactioncustom.com on behalf of william key Monday, September 30, 2019 9:41 AM PUBLICE NOTICE TENNCARE [EXTERNAL] It is time the Tn quit bowing at the alter of the almighty dollar and started supporting the needs of its citizens - Oppose the Medicaid Block Grant Proposal.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  william key  3314 Turtle Cove Dr  Louisville, TN 37777‐3322 keyws1@gmail.com  17 Jonathan Reeve From: Sent: To: Subject: bfaccia@everyactioncustom.com on behalf of Barbara Faccia Monday, September 30, 2019 9:43 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Barbara Faccia  1051 W Main St  Franklin, TN 37064‐1903  bfaccia@aol.com  18 Jonathan Reeve From: Sent: To: Subject: wallace@everyactioncustom.com on behalf of Wallace Harvill Monday, September 30, 2019 10:13 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Wallace Harvill  820 Highway 100  Centerville, TN 37033‐1170 wallace@harvill‐law.com  19 Jonathan Reeve From: Sent: To: Subject: lisa37027@everyactioncustom.com on behalf of Lisa Headley Monday, September 30, 2019 10:13 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tennessee's Medicaid block proposal - NO GOOD   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Lisa Headley  624 Split Rail Dr  Brentwood, TN 37027‐5737 lisa37027@aol.com  20 Jonathan Reeve From: Sent: To: Subject: lovellkd@everyactioncustom.com on behalf of Kim Lovell Monday, September 30, 2019 10:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] We should not move forward with the Medicaid block grant proposal   Dear Gabe Roberts,    I wanted to reach out and express my opposition to the proposal to radically change Tennessee’s Medicaid partnership  with the federal government by converting federal funding for TennCare into a “block grant.” I believe this proposal  would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     I work for Vanderbilt University Medical Center, where we focus on improving the health of children and families.  Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  the vital health coverage they need and is a program that has helped thousands of people in TN and in our health system gain coverage to needed care. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The proposal could cut back on core health care services like  hospital care, without federal approval or public notice, and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kim Lovell  1830 A 9th Ave N  Nashville, TN 37208‐1524 lovellkd@gmail.com  21 Jonathan Reeve From: Sent: To: Subject: guymhicks@everyactioncustom.com on behalf of Guy Hicks Monday, September 30, 2019 10:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am strongly opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would create great risk of  immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Guy Hicks  20 Wynstone  Nashville, TN 37215‐5800  guymhicks@gmail.com  22 Jonathan Reeve From: Sent: To: Subject: walnutvalleytn@everyactioncustom.com on behalf of cecile allen Monday, September 30, 2019 10:59 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Please, please vote against this proposal which would so adversely affect so many of the most vulnerable of our state.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  mrs cecile allen  8505 Beech Valley Rd  Primm Springs, TN 38476‐1703 walnutvalleytn@gmail.com  23 Jonathan Reeve From: Sent: To: Subject: lraynor95@everyactioncustom.com on behalf of Larkin Raynor Monday, September 30, 2019 11:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Larkin Raynor  122 Oceola Ave  Nashville, TN 37209‐3114 lraynor95@gmail.com  24 Jonathan Reeve From: Sent: To: Subject: tbynum@everyactioncustom.com on behalf of Thomas Bynum Monday, September 30, 2019 11:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Thomas Bynum  1425 Stainback Ave  Nashville, TN 37207‐5163 tbynum@tnjustice.org  25 Jonathan Reeve From: Sent: To: Subject: dalidaisy@everyactioncustom.com on behalf of Sheri MacAleese Monday, September 30, 2019 11:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Sheri MacAleese  1412 Francis Station Dr  Knoxville, TN 37909‐1123 dalidaisy@hotmail.com  26 Jonathan Reeve From: Sent: To: Subject: vzapata@everyactioncustom.com on behalf of Vanessa Zapata Monday, September 30, 2019 11:42 AM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Our state has not taken steps to ensure preventative health care so how can we look the other way when health  problems become exacerbated? We tout the idea of getting on your own two feet and working hard to pave your path  to success but we cannot ignore the fact that the path is not equal for all. Many paths require more effort and pain to be  paved.     I work for an organization that helps Tennesseans who are struggling to make ends meet and who cannot care for  themselves and their loved ones because of expensive health issues. It is so painful to hear their stories and to see how  helpless they feel. It is a happy day when we have figured out how our clients are qualified for TennCare ‐ though many  are not. The Medicaid Block Grant Proposal will just increase anxiety, pain and suffering among low income  Tennesseans. For those that have serious health care problems this proposal will effectively shorten their life  expectancy.     Sincerely,  Vanessa Zapata  Nashville, TN 37212  vzapata@tnjustice.org  27 Jonathan Reeve From: Sent: To: Subject: christinahembree@everyactioncustom.com on behalf of Christina Sullivan Tuesday, October 1, 2019 12:20 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to this proposal of a block grant.  From what I have researched, its just going to make services for the  disabled and elderly less available.  Since it is 1 a.m., and yes I do work tomorrow, but I'm up taking care of a special  needs 24 year old, I'll make this short.  Its a stupid and not a very well thought out plan designed to save money by  denying vital healthcare to those who are most expensive...essentially allowing them to die off.  So yes, yes I am officially opposed.  Thank you for your time and consideration in this matter.  sincerely,  Chris Sullivan(tennessean since 1988)    Sincerely,  Christina Sullivan  270 Old Clover Hill Rd  Maryville, TN 37803‐0569 christinahembree@aol.com  28 Jonathan Reeve From: Sent: To: Subject: perlie@everyactioncustom.com on behalf of Perlie Murray-Dunn Tuesday, October 1, 2019 1:17 AM PUBLICE NOTICE TENNCARE [EXTERNAL] as a former employee of Department Of Human Services who worked in the Medicaid program, I know the Block Grant will be detrimental to Tennesseans that are in need of health care. There must be some accountability in order to ensure the prog...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilitie s, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Perlie Murray‐Dunn  3905 Augusta Dr  Nashville, TN 37207‐3503 perlie@bellsouth.net  29 Jonathan Reeve From: Sent: To: Subject: kimtroup@everyactioncustom.com on behalf of Kim Troup Tuesday, October 1, 2019 4:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tennessee’s Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. Over the years, vulnerable Tennesseans, particularly children have been  kicked off the program, many times without any notification.  The state should not be allowed to make changes to the  Medicaid program without federal oversight or eliminate federal standards, which are in place for the protection of  patients. Without such guardrails, the state could return to the days when managed care contractors failed to provide  care to patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of  vital health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Kim Troup  418 English Ivy Dr  Nashville, TN 37211‐7140 kimtroup@hotmail.com  30 Jonathan Reeve From: Sent: To: Subject: handds2004@everyactioncustom.com on behalf of Dianne Hand Tuesday, October 1, 2019 6:28 AM PUBLICE NOTICE TENNCARE [EXTERNAL] This proposal is harmful to Tennessee and to the children who need it most.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Dianne Hand  120 Woodland Rd  Winchester, TN 37398‐4424 handds2004@yahoo.com  31 Jonathan Reeve From: Sent: To: Subject: kmeier590@everyactioncustom.com on behalf of Kathleen Meier Tuesday, October 1, 2019 6:40 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. I am a healthcare professional and cannot stand by silently while politicians deny  Tennesseans healthcare coverage.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kathleen Meier  758 N Mclean Blvd  Memphis, TN 38107‐5114 kmeier590@gmail.com  32 Jonathan Reeve From: Sent: To: Subject: handds2004@everyactioncustom.com on behalf of Dianne Hand Tuesday, October 1, 2019 6:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] This proposal is harmful to Tennessee and the children who need it the most.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Dianne Hand  120 Woodland Rd  Winchester, TN 37398‐4424 handds2004@yahoo.com  33 Jonathan Reeve From: Sent: To: Subject: lindaleecrouch@everyactioncustom.com on behalf of Linda Crouch Tuesday, October 1, 2019 6:47 AM PUBLICE NOTICE TENNCARE [EXTERNAL] 26 years of teaching young children in Tennessee gives me the knowledge of how important it is for all children to have the ability to be properly cared for when medical needs become apparent. These young children have no voice but that of c...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Linda Crouch  395  Andersonville, TN 37705  lindaleecrouch@gmail.com  34 Jonathan Reeve From: Sent: To: Subject: clhoot@everyactioncustom.com on behalf of Cathy Hoot Monday, September 30, 2019 9:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    The most vulnerable Tennesseans will be hurt by Block Grants for Tennessee's TennCare program. I am opposed to the  proposal to radically change Tennessee’s Medicaid partnership with the federal government by converting federal  funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Cathy Hoot  129 Carnousti Dr  Franklin, TN 37069‐7022 clhoot@bellsouth.net  35 Jonathan Reeve From: Sent: To: Subject: chinamoon1420@everyactioncustom.com on behalf of Leesa Wright Monday, September 30, 2019 10:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Leesa Wright  7311 Meacham Ln  Hixson, TN 37343‐2980  chinamoon1420@aol.com  36 Jonathan Reeve From: Sent: To: Subject: PatMorganAuthor@everyactioncustom.com on behalf of Pat Morgan Monday, September 30, 2019 10:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am unalterably opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm  and jeopardize coverage for vulnerable Tennesseans. In fact, by no means do I trust the State Legislature to do the right  thing with any funds they would receive from the block grant.  Further, it was cuts in funding for mental health through  block grants that brought us homelessness on a scale the nation had ever seen and has yet to effectively address.       Medicaid's IMD Exclusion had already left untold thousands of people with severe mental illness without access to the  inpatient treatment they desperately need to break the stranglehold of the streets and stay out of jail for "crimes" that  are a direct result of their mental illness. The block grants were the final nail in the coffin. More block grants would make it even worse.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.   TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Pat Morgan  180 Marrakesh Cir  Memphis, TN 38103‐5830 PatMorganAuthor@comcast.net  37 Jonathan Reeve From: Sent: To: Subject: shanbmowr70@everyactioncustom.com on behalf of Shannon Mowrer Monday, September 30, 2019 4:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Shannon Mowrer  1225 Helena Dr  Hixson, TN 37343‐3906  shanbmowr70@epbfi.com  38 Jonathan Reeve From: Sent: To: Subject: mattferrytnez@everyactioncustom.com on behalf of Matt Ferry Monday, September 30, 2019 3:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am one among thousands of Tennesseans who oppose the proposal to radically change Tennessee’s Medicaid  partnership with the federal government by converting federal funding for TennCare into a “block grant.” This proposal  would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Matt Ferry  1501 Belle Oaks Dr  Murfreesboro, TN 37130‐1931 mattferrytnez@gmail.com  39 Jonathan Reeve From: Sent: To: Subject: galecourtneymoore@everyactioncustom.com on behalf of Gale Moore Monday, September 30, 2019 5:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Please listen to those who have experience with these matters. We can not use trail and error on such important issues.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Gale Moore  917 W 7th St  Columbia, TN 38401‐3055  galecourtneymoore@mcewengroup.com  40 Jonathan Reeve From: Sent: To: Subject: taylorcdhancock@everyactioncustom.com on behalf of Taylor Hancock Monday, September 30, 2019 4:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, including myself.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Taylor Hancock  1707 6th Ave N  Nashville, TN 37208‐2217 taylorcdhancock@gmail.com  41 Jonathan Reeve From: Sent: To: Subject: bord2585@everyactioncustom.com on behalf of Johnny Borders Monday, September 30, 2019 6:45 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Johnny Borders  PO Box 302  Helenwood, TN 37755‐0302  bord2585@gmail.com  42 Jonathan Reeve From: Sent: To: Subject: rickmariedudley@everyactioncustom.com on behalf of Marie Dudley Monday, September 30, 2019 7:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] This act would mean homicide to the people of Tennessee, the very people who often do not know where there next meal will come from, or if they will have a next meal. This will certainly push a segment of our population into a 3rd World clas...   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Marie Dudley  PO Box 352  Bon Aqua, TN 37025‐0352  rickmariedudley@bellsouth.net  43 Jonathan Reeve From: Sent: To: Subject: dwcasto@everyactioncustom.com on behalf of Donald Casto Monday, September 30, 2019 12:12 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     I live in rural Tennessee. I see the hospital and clinic closures, and the resulting decline in health care options.   Tennessee needs to provide more access to medical care, not less. Too many citizens are suffering and dying.         Sincerely,  Donald Casto  4393 Cedar St  Centerville, TN 37033‐5940 dwcasto@gmail.com  44 Jonathan Reeve From: Sent: To: Subject: egan2031@everyactioncustom.com on behalf of Lynn Egan Monday, September 30, 2019 2:10 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I oppose the proposal to radically change Tennessee’s Medicaid partnership with the federal government by converting  federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for  vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  Sincerely,   Lynn Egan    Sincerely,  Ms Lynn Egan  Brentwood, TN 37027  egan2031@outlook.com  45 Jonathan Reeve From: Sent: To: Subject: dennissecalle27@everyactioncustom.com on behalf of Dennisse Calle Monday, September 30, 2019 2:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dennisse Calle  611 Hollow Crst  Clarksville, TN 37042‐1711 dennissecalle27@gmail.com  46 Jonathan Reeve From: Sent: To: Subject: paulayeatman033@everyactioncustom.com on behalf of Paula Yeatman Monday, September 30, 2019 2:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Good health care is a right which should not be taken away.    Sincerely,  Paula Yeatman  107 Blackberry Ln  Sewanee, TN 37375‐4017 paulayeatman033@gmail.com  47 Jonathan Reeve From: Sent: To: Subject: sjgriffin72112@everyactioncustom.com on behalf of Stephanie Griffin Monday, September 30, 2019 2:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.          My patient is completely dependent on medical staff, medical equipment, and medical supplies  to keep her alive.  She is  unable to perform any task of daily living without these, from the very essence of breathing, eating through a PEG,  keeping her airway clear with suctioning, and having her medications to keep her in good health. Without Tenncare my  patient could not, and would not, have the necessities to sustain her life.  I strongly oppose any change whatsoever.      Sincerely,  Stephanie Griffin  33160 Highway 104 S  Reagan, TN 38368‐6239 sjgriffin72112@gmail.com  48 Jonathan Reeve From: Sent: To: Subject: stamperjulia@everyactioncustom.com on behalf of Julia Stamper Monday, September 30, 2019 2:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Julia Stamper  Nashville, TN 37205  stamperjulia@gmail.com  49 Jonathan Reeve From: Sent: To: Subject: norfolkryan@everyactioncustom.com on behalf of Debra Poppelaars Monday, September 30, 2019 2:26 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Debra Poppelaars  8075 Sawyer Brown Rd  Nashville, TN 37221‐1525 norfolkryan@yahoo.com  50 Jonathan Reeve From: Sent: To: Subject: jillmthrshd@everyactioncustom.com on behalf of Jill Mothershed Monday, September 30, 2019 2:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Jill Mothershed  308 Emery Dr  Nashville, TN 37214‐3114  jillmthrshd@gmail.com  51 Jonathan Reeve From: Sent: To: Subject: warreng58@everyactioncustom.com on behalf of Grady Warren Monday, September 30, 2019 2:53 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Grady Warren  317 May St  Lawrenceburg, TN 38464‐2526  warreng58@yahoo.com  52 Jonathan Reeve From: Sent: To: Subject: hepcatfox@everyactioncustom.com on behalf of Stephanie Fox Monday, September 30, 2019 2:52 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I Oppose the Medicaid Block Grant Proposal   Dear Gabe Roberts,    Tennessee’s Medicaid partnership with the federal government should NOT be changed to convert federal funding for  TennCare into a “block grant.”The block grant proposal would cause extreme harm as well as jeopardize coverage for  vulnerable Tennesseans.     Healthcare is a human right and this proposal gives Tennessee new authority to cut services for vulnerable populations.  The state could eliminate or restrict services like physical therapy, hospice, and transplant coverage without normal  federal oversight – and arbitrarily limit who gets them. The proposal could also cut back on core health care services like  hospital care, without federal approval or public notice, and exclude coverage of high‐cost prescription drugs.     Block grants are a very bad idea ‐ what happens when there are fluctuations in the number of people that need  coverage or there is a spike in costs? We shouldn't let people go without healthcare and/or die because the block grant  is used up.    No one in good conscience could support this proposal. Please do not go forward with this harmful proposal.    Sincerely,  Stephanie Fox  Nashville, TN 37216  hepcatfox@juno.com  53 Jonathan Reeve From: Sent: To: Subject: kimsings3@everyactioncustom.com on behalf of Kim Young Monday, September 30, 2019 2:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] PLEASE PROTECT TN. residents health from block grants! WHY are children in Tennessee losing health care coverage?   Dear Gabe Roberts,    I am ADAMANTLY OPPOSED to the proposal to RADICALLY CHANGE Tennessee’s Medicaid partnership with the federal  government by converting federal funding for TennCare into a “block grant.” This ill‐conceived proposal would cause  more than immense harm and jeopardize coverage for many thousands of vulnerable Tennesseans that can least afford  such changes!!! PLEASE DO NOT ALLOW THIS TERRIBLE PROPOSAL TO GO FORWARD!!! GOOD PEOPLE WILL DIE IF THIS  PROPOSAL EVER TAKES EFFECT!!!    And just for the record neither I, nor anyone in my family receives TennCare medical services, but i care deeply for the  people of TN. that do receive them.    Medicaid was createdTO HELP children, people with disabilities, pregnant women, and other vulnerable Americans get  CRUCIALLY NEEDED HEALTH CARE. This proposal goes COMPLETELY AGAINST THE OBJECTIVES OF MEDICAID because it  gives Tennessee new authority to CUT MUCH NEEDED SERVICES for these vulnerable populations!! The state of  Tennessee has already cut services and denied health care to around 200,000 children, that's 200,000 needy children  and it beyond despicable!!!! The state could eliminate or restrict services like physical therapy, hospice, and transplant  coverage without normal federal oversight – AND arbitrarily limit who gets them. TO ALLOW THIS TO HAPPEN WOULD  BE A HORRIFIC THING!! The proposal could also cut back on CORE HEALTH CARE SERVICES like hospital care, without  federal approval or public notice, and exclude coverage of high‐cost prescription drugs. TN ALREADY LEADS THE NATION  IN RURAL HOSPITAL CLOSURES LEAVING MANY HUNDREDS OF THOUSANDS WITHOUT ADEQUATE EMERGENCY  SERVICES!!!!! PLEASE DENY THIS DESPICABLE PROPOSAL FOR THE SAKE OF TN. RESIDENTS IN NEED, I BEG YOU!!      TENNCARE DEFINITELY NEEDS MUCH MORE ACCOUNTABILITY, NOT LESS!!!!!!!     The state should NOT be allowed to make changes to the Medicaid program WITHOUT federal oversight OR eliminate  federal standards, which are in place for THE TRUE PROTECTION of patients. Without such guardrails, the state could  return to the days when managed care contractors FAILED MISERABLY TO PROVICE MUCH NEEDED CARE to patients and  providers were left unpaid. This proposal absolutely invites fraud and abuse and threatens the very availability of vital  health coverage for thousands of Tennesseans!!!! PLEASE DO NOT ALLOW THIS TERRIBLE PROPOSAL TO EVER SEE THE  LIGHT OF DAY!!!!!     This waiver is horribly and fundamentally flawed and CANNOT BE FIXED!!! It absolutely goes against the goals AND  purpose of the Medicaid program. We respectfully and strongly URGE YOU TO NEVER GO FORWARD WITH THIS SHORT  SIGHTED AND VERY HARMFUL PROPOSAL!!! THE MANY THOUSANDS OF TENNESSEANS IN NEED OF TENNCARE WILL  HEARTILY THNAK YOU!!!!    Sincerely,  Mr. Kim Young  1040 Big Tom Rd  Kingston Springs, TN 37082‐5100 kimsings3@yahoo.com  54 Jonathan Reeve From: Sent: To: Subject: rcs1565@everyactioncustom.com on behalf of Lida Stewart Monday, September 30, 2019 2:55 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Do NOT change TennCare to a block grant!   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lida Stewart  Nashville, TN 37209  rcs1565@yahoo.com  55 Jonathan Reeve From: Sent: To: Subject: teresa@everyactioncustom.com on behalf of Teresa Nothan Monday, September 30, 2019 3:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Stop the Block Grant   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Teresa Nothan  242 Heritage Park Dr Ste 105 Murfreesboro, TN 37129‐1551 teresa@thbdf.org  56 Jonathan Reeve From: Sent: To: Subject: chrysalis.fae@everyactioncustom.com on behalf of Lisa Stuart Monday, September 30, 2019 3:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lisa Stuart  102  Hendersonville, TN 37075  chrysalis.fae@gmail.com  57 Jonathan Reeve From: Sent: To: Subject: rc14495@everyactioncustom.com on behalf of Richard Chambers Monday, September 30, 2019 3:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Please ignore the politics and think of Tennessee's most needful.    Sincerely,  Richard Chambers  855 Pasadena Dr  Nashville, TN 37204‐4223 rc14495@gmail.com  58 Jonathan Reeve From: Sent: To: Subject: debbiehunziker@everyactioncustom.com on behalf of Debbie Hunziker Monday, September 30, 2019 3:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Debbie Hunziker  297 Hunziker Rd  Tracy City, TN 37387‐0018 debbiehunziker@yahoo.com  59 Jonathan Reeve From: Sent: To: Subject: v.n.crawford@everyactioncustom.com on behalf of Valerie Crawford Monday, September 30, 2019 3:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Valerie Crawford  1325 General George Patton Rd  Nashville, TN 37221‐2445 v.n.crawford@gmail.com  60 Jonathan Reeve From: Sent: To: Subject: Mary Hansard Tuesday, October 1, 2019 7:56 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Please do not let the block grant happen! In my opinion, block grant will not support the people in Tennessee who need  healthcare!  61 Jonathan Reeve From: Sent: To: Subject: Trish Goedecke Tuesday, October 1, 2019 7:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] No to block grant; yes to Memphis hearing ~   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Tennessee representatives ~ Governor Lee wants to reduce TennCare spending and remove federal oversight of his funds are spent. We know how that’s likely to go for Memphians, who are the most in need of TennCare support. Please choose to meet the medical and financial needs of our deserving, underserved citizens, rather than raid the TennCare coffers for other state purposes.   Thank you ~   Trish Goedecke  ~~<>~~~~~~~<>~~~~<>~~~~~~~<>~~  trish.goedecke@gmail.com  Memphis TN 38104  62 Jonathan Reeve From: Sent: To: Subject: phwilliams2@everyactioncustom.com on behalf of Patricia Williams Monday, September 30, 2019 10:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Patricia Williams  4301 Elkins Ave  Nashville, TN 37209‐3643 phwilliams2@comcast.net  63 Jonathan Reeve From: Sent: To: Subject: Catherine Henschen Monday, September 30, 2019 8:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TN Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom it May Concern:    We believe the move to reject Medicaid expansion and then to replace it with the proposed block grant program is a  politically motivated move that lacks evidence on its effectiveness and will result in Tennesseans who will not be able to  access health care. We urge you to reject the request for these block grants. If our legislators and governor wish to be  responsible, they will drop this sham and expand Medicaid. Vulnerable patients here in Tennessee are depending on  you.    Thank you,     Catherine and Bruce Henschen  Knoxville, Tennessee  64 Jonathan Reeve From: Sent: To: Subject: bechtels4 Monday, September 30, 2019 8:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TN Care Comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***     Governor Lee, and TN Legislators,    As a resident of TN, and the parent of an individual with a significant disability, I would like to provide you with perspective.    The Medicare Block Grant program is untested, illegal, and targets cost savings based on reducing care/cost of care to individuals with significant disabilities or illness.   Quote  "TJC Staff Attorney Gordon Bonnyman said 10% of TennCare patients, many chronically ill or with disabilities, account for more than half of TennCare spending."    I have worked for 22 years to help my young adult grow towards independence in a country, and now in a state, that does not provide adequate support to families and patients with disabilities.    It is estimated that individuals with disabilities can cost a family$1M on average more than a typical peer. Where resources are already inadequate, you are proposing to reduce spending by $2B. It is ridiculous to believe that this will not reduce services.    Expand Medicaid, and bring TN into the modern age, providing patients with needed mental and physical health care from an early age. Give these patients their best shot to grow into independent adults.    The best outcomes for people with life challenges could provide dignity, independence, and contribute to the economy.     Shortchanging these individuals burdens families and government with life long costs, dependency, and impossible choices between siblings/support.    I cannot condone your block grant plan, and do not believe that it is workable.      Mary Isaac  11421 Turkey Creek Rd   Knoxville,TN 37934        Sent from my Verizon, Samsung Galaxy smartphone  65 Jonathan Reeve From: Sent: To: Subject: Stephanie Fletcher Monday, September 30, 2019 6:38 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I am opposed to Governor Lee’s Medicaid block grant proposal. It will do nothing to improve access to care for the  uninsured or those in rural areas. Access to quality health care should be a fundamental right, not a bargaining tool or a  political ploy. Allowing politicians to be in charge of decisions affecting the health of Tennesseans as a way to save  money is reprehensible. Please make decisions based on compassion and care, not the Republican Slate of Hate.     Stephanie Fletcher  5228 Malibu Drive   Knoxville, TN 37918  Message sent from my iPhone  66 Jonathan Reeve From: Sent: To: Subject: kimberlylaakso@everyactioncustom.com on behalf of Kimberly Laakso Monday, September 30, 2019 5:21 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans, including myself. I am a stroke survivor and depends on TennCare to cover the  costs that I cannot pay.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Kimberly Laakso  789 Jolly Springs Rd  Dresden, TN 38225‐2251 kimberlylaakso@gmail.com  67 Jonathan Reeve From: Sent: To: Subject: Amy Teague Monday, September 30, 2019 2:57 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I strongly oppose this measure. Please do not consider block grants for Tenncare.   Amy Teague  37642     Sent from my iPad  68 Jonathan Reeve From: Sent: To: Subject: sdkharif@everyactioncustom.com on behalf of Shakura Kharif Monday, September 30, 2019 2:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Shakura Kharif  2661 Lake Valley Dr  Cookeville, TN 38506‐7451 sdkharif@gmail.com  69 Jonathan Reeve From: Sent: To: Subject: Kristi Stephens Walker Monday, September 30, 2019 12:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid block grant is not good for Tennesseans   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Director Roberts,  Please reconsider, and do everything in your power to see that Medicaid does not become a block grant, as Gov. Bill  Lee's proposes. This will hurt Tennesseans who are already vulnerable and uninsured, not to mention rural hospitals.  This is not helpful  to Tennesseans who need care the most. Please use your position ad power to assist with our most  vulnerable citizens.  Thank you,  Kristi Walker  Nashville, TN      ‐‐   Kristi Stephens Walker  krististephenswalker@gmail.com  615.977.0028  71 Jonathan Reeve From: Sent: To: Subject: Walls, Madeline Monday, September 30, 2019 12:08 PM PUBLICE NOTICE TENNCARE [EXTERNAL] The governor's proposed block grant is dangerous and jeopardizes current enrollees in Medicaid.   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Gabe Roberts and others,    There is a better plan than the proposal for the block grant. I support the legislature expanding  Medicaid instead.    The Governor’s block grant proposal does nothing to provide coverage for 675,000+  Tennesseans without any health insurance. It also risks benefits and coverage for current  Medicaid enrollees.    Respectfully,  Madeline Walls  4406 Westlawn Drive  Nashville, TN 37209  615‐385‐4794    72 Jonathan Reeve From: Sent: To: Subject: Kevin Walker Monday, September 30, 2019 12:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  To Whom It May Concern,  I am writing to share that I am opposed to the proposal to block grant Medicaid in Tennessee. As a citizen of this state, I  want our agency (I am a TennCare employee) to always have the funds available to provide needed health care for the  poorest Tennesseans in the event of an economic downturn or state health emergency. Making Medicaid a block grant  removes that flexibility and assurance that we will care for one another. Block grants will inevitably lead to rationing  care by cutting services. Please do not more forward with this plan.    Kevin Walker  3209 Cloverwood Drive  Nashville, TN 37214    Sent from my iPhone  73 Jonathan Reeve From: Sent: To: Subject: Ralph Goodman Monday, September 30, 2019 10:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenn Care Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To whom it may concern  I want to go on record as opposing the Tenn Care Block grant proposal.  It is designed to reduce medicaid spending thus  less people will be insured.  We have a an opioid crisis, hospitals closing down and 380,000 uninsured Tennesseans due  to Tennessee not expanding medicaid.  We don't need to reduce funding for health care we need to expand. We need to  simply expand medicaid like 36 other progressive states have done.   If you want to reduce costs do something about  reducing the cost of drugs and healthcare not Tennesseans access to healthcare.    74 Jonathan Reeve From: Sent: To: Subject: anwhitver@everyactioncustom.com on behalf of Anne Whitver Sunday, September 29, 2019 8:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Anne Whitver  Nashville, TN 37209  anwhitver@gmail.com  75 Jonathan Reeve From: Sent: To: Subject: cmdortch@everyactioncustom.com on behalf of Chris Dortch Sunday, September 29, 2019 8:14 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Chris Dortch  Ooltewah, TN 37363  cmdortch@comcast.net  76 Jonathan Reeve From: Sent: To: Subject: eav8@everyactioncustom.com on behalf of Emily Vergho Sunday, September 29, 2019 12:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans like my son.     My adult son has autism.  He has very limited speech and is unable to work or live independently.  I am 70 and he lives  with me. He currently receives  services through TennCare and Medicare.  Providing medical services for him is a  challenge due to the few providers willing to accept Medicare and TennCare and due to his inability to communicate  effectively.  A PA stays with him when I am out of the house because he cannot communicate, cook, and might open the  door to strangers. He requires assistance in doing chores.  In case of an emergency, he would not know what to do.  In  prior years I have only been able to work because he received services enabling me to hold down a job.  Now Tennessee  wants to change the way they receive funding which will no longer guarantee funding by individual.  I have no reason to  believe my son's needs will be met or that adequate funding will be available under a block grant.  In fact a block grant is  a benefit to those who wish to eliminate funding increases and who wish to divert funding from individuals to "other  priorities." Based on the difficulty in getting services in the past I can only assume that a block grant would make  services unavailable for many like my son.  I doubt that there would be adequate oversight.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.  I believe this proposal would harm my son, as  well as other vulnerable Tennessee citizens.    Sincerely,  Emily Vergho  3216 Longacre Cv  Memphis, TN 38134‐3134 eav8@bellsouth.net  77 Jonathan Reeve From: Sent: To: Subject: gonceling@everyactioncustom.com on behalf of Colleen Whitver Sunday, September 29, 2019 4:20 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Colleen Whitver  409 Brook Hollow Rd  Nashville, TN 37205‐3505 gonceling@gmail.com  78 Jonathan Reeve From: Sent: To: Subject: jtaylor@everyactioncustom.com on behalf of Jerry Taylor Sunday, September 29, 2019 8:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. While it is being promoted as a cost‐saving measure for the  federal government, it is at best a penny‐wise and pound‐foolish proposal that ultimately is not in the federal  government's interest either.       I know from personal experience, both as a former state attorney and as an advocate for TennCare/Medicaid enrollees,  that the State of Tennessee cannot be trusted to do what is right in protecting the rights of TennCare enrollees while  also protecting the integrity of the TennCare program.  If anything, Tennessee needs more federal oversight ‐‐ not less  oversight in favor of what the State euphemistically calls "flexibility."    This block grant proposal is founded on the self‐serving political motives of the Tennessee General Assembly, aided and  abetted by a first term governor who cannot or will not stand up to the political pressure and protect the medically and  economically vulnerable citizens of Tennessee.  The TennCare enrollees ‐ and all the citizens of Tennessee‐ need and  deserve the protections in the  Medicaid law and regulations.  I urge you to respect and maintain those protections by  rejecting this block grant proposal.        Sincerely,  Jerry Taylor  222 2nd Ave S Ste 2000 Nashville, TN 37201‐2385 jtaylor@burr.com  79 Jonathan Reeve From: Sent: To: Subject: martinezann2122@everyactioncustom.com on behalf of Ann Martinez Sunday, September 29, 2019 8:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    Block granta mean less people covered.  Rural hospitals are closing at an alarming rate. I am opposed to the proposal to  radically change Tennessee’s Medicaid partnership with the federal government by converting federal funding for  TennCare into a “block grant.” This proposal would cause immense harm and jeopardize coverage for vulnerable  Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ann Martinez  Memphis, TN 38134  martinezann2122@gmail.com  80 Jonathan Reeve From: Sent: To: Subject: orgrits@everyactioncustom.com on behalf of Wendy Clark Sunday, September 29, 2019 8:30 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs Wendy Clark  Hixson, TN 37343  orgrits@aol.com  81 Jonathan Reeve From: Sent: To: Subject: umcpastorkcb@everyactioncustom.com on behalf of Kristin Clark Banks Sunday, September 29, 2019 4:19 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kristin Clark Banks  Nolensville, TN 37135  umcpastorkcb@gmail.com  82 Jonathan Reeve From: Sent: To: Subject: karen.mcintyre@everyactioncustom.com on behalf of Karen McIntyre Sunday, September 29, 2019 8:37 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” It appears that the real purpose here is to reduce the  number of people served in order to lower costs!   This proposal puts the most vulnerable Tennesseans who are already underserved at risk.    Medicaid was created to help children, people with disabilities, pregnant women, and other Americans get vital health  coverage they need. This proposal defeats those objectives.      Medicaid because it gives Tennessee new authority to cut services for these vulnerable populations. The state could  eliminate or restrict services like physical therapy, hospice, and transplant coverage without normal federal oversight –  and arbitrarily limit who gets them. The proposal could also cut back on core health care services like hospital care,  without federal approval or public notice, and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms Karen McIntyre  2501 Ravine Dr  Nashville, TN 37217‐3614 karen.mcintyre@mnps.org  83 Jonathan Reeve From: Sent: To: Subject: mstevens931@everyactioncustom.com on behalf of Michael Stevens Sunday, September 29, 2019 8:38 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Michael Stevens  236 Woodson Dr  Tullahoma, TN 37388‐4126 mstevens931@lighttube.net  84 Jonathan Reeve From: Sent: To: Subject: jonathanmarx@everyactioncustom.com on behalf of Jonathan Marx Sunday, September 29, 2019 8:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Jonathan Marx  921 Montrose Ave  Nashville, TN 37204‐2623 jonathanmarx@bellsouth.net  85 Jonathan Reeve From: Sent: To: Subject: glenn_m@everyactioncustom.com on behalf of Glenn McReynolds Sunday, September 29, 2019 4:43 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Glenn McReynolds  266 38th Ave N  Nashville, TN 37209‐4806 glenn_m@tndisability.org  86 Jonathan Reeve From: Sent: To: Subject: seh1955@everyactioncustom.com on behalf of Sharon Hill Sunday, September 29, 2019 8:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the block grant program for Medicaid.     Governor Lee should be ashamed of himself for promoting a program that will hurt the least among us.         Sincerely,  Ms Sharon Hill  Nashville, TN 37205  seh1955@gmail.com  87 Jonathan Reeve From: Sent: To: Subject: paulelliottjr@everyactioncustom.com on behalf of Paul Elliott Sunday, September 29, 2019 8:51 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Paul Elliott  411 Orr St  Chattanooga, TN 37405‐3647  paulelliottjr@icloud.com  88 Jonathan Reeve From: Sent: To: Subject: bmostello1@everyactioncustom.com on behalf of Beckie Mostello Sunday, September 29, 2019 5:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Beckie Mostello  330 Shadow Creek Dr  Brentwood, TN 37027‐7869 bmostello1@gmail.com  89 Jonathan Reeve From: Sent: To: Subject: hockmary@everyactioncustom.com on behalf of MARY HOCK Sunday, September 29, 2019 5:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Critical needs for families in Tennessee   Dear Gabe Roberts,    As a social worker for the past 25 years in Tennessee, I am opposed to the proposal to radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans. I have worked with  individuals and families who have relied on TennCare in so many different ways:  for help with elderly relatives who are  ill, so that other family member can continue to work; for coverage for special needs children (and adults) whose health  care costs without TennCare would certainly bankrupt the family; for pregnant teens whose TennCare coverage ensured  a healthy outcome for their baby.  Because of a healthy birth, that  baby, a Tennessee citizen, will grow up positively  contribute to our state.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. MARY HOCK  2613 Mesa Dr  Nashville, TN 37217‐3901  hockmary@gmail.com  90 Jonathan Reeve From: Sent: To: Subject: lisaeellis59@everyactioncustom.com on behalf of Lisa Ellis Sunday, September 29, 2019 5:25 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Lisa Ellis  1116 Edbury Dr  Knoxville, TN 37922‐8015 lisaeellis59@gmail.com  91 Jonathan Reeve From: Sent: To: Subject: manyblessings441@everyactioncustom.com on behalf of Dr Jane Roach Sunday, September 29, 2019 5:29 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     I practiced pediatrics in Ohio for 30 years, and was always happy to help my Medicaid patients. It was such a good move  for children and people with disabilities and cancer, when our Republican Governor, John Kasich, expanded Medicaid  benefits in our state.  Immediately after passage, over 26,000 patients received coverage for their cancer treatment!!  And it continues to help the needy in Ohio.    TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr Jane Roach  Brentwood, TN 37027  manyblessings441@gmail.com  92 Jonathan Reeve From: Sent: To: Subject: dianeshulman53@everyactioncustom.com on behalf of Judith Diane Shulman Sunday, September 29, 2019 9:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Judith Diane Shulman  108 Nestledown Xing  Bell Buckle, TN 37020‐3930 dianeshulman53@gmail.com  93 Jonathan Reeve From: Sent: To: Subject: bwheeler58941@everyactioncustom.com on behalf of Betsy Wheeler Sunday, September 29, 2019 9:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Betsy Wheeler  200 Peacock St  Bell Buckle, TN 37020‐3915 bwheeler58941@gmail.com  94 Jonathan Reeve From: Sent: To: Subject: riverdoc@everyactioncustom.com on behalf of Laura Helfman Sunday, September 29, 2019 5:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    As an Emergency Physician who takes care of many of our disadvantaged citizens, I feel very qualified to register my  STRONG OPPOSITION to Governor Lee's plan to apply for a block grant.  This would radically change Tennessee’s  Medicaid partnership with the federal government by converting federal funding for TennCare into a “block grant.” This  proposal would cause immense harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.        Sincerely,  Dr. Laura Helfman  297 Sunset Vista Rd  Coalmont, TN 37313‐7906 riverdoc@outlook.com  95 Jonathan Reeve From: Sent: To: Subject: diana.page@everyactioncustom.com on behalf of Diana Page Sunday, September 29, 2019 10:07 AM PUBLICE NOTICE TENNCARE [EXTERNAL] A Medicaid Block Grant will further undermine progess   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Unfortunately, recent history has demonstrated that the State of TN does not appear to be able to successfully handle  this responsibility.    Sincerely,  Diana Page  6708 Autumnwood Dr  Nashville, TN 37221‐3943 diana.page@comcast.net  96 Jonathan Reeve From: Sent: To: Subject: mcmullen1@everyactioncustom.com on behalf of W.McMullen Sunday, September 29, 2019 10:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant Proposal Is Harmful to health of our citizens. Healthier Medicaid Citizens is an urgent cost effective need.   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. W. McMullen  8348 Colton Cv  Germantown, TN 38139‐3249 mcmullen1@aol.com  97 Jonathan Reeve From: Sent: To: Subject: Lgentry492@everyactioncustom.com on behalf of Linda Gentry Sunday, September 29, 2019 6:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. I am one of them and my son which I have Melanoma Cancer and since have had  Immunotherapy that was just a trail and arrow to help Me with Melanoma Cancer Stage 4 was a horrible Life Change For  Me To Hear. The Doctor just maybe would give me just a little time if the Drug worked On Me as My Health and What I  was going threw At a Fast Pace of Time.The first thing was to get as much Testing and MRI’s and CT’s and Blood Work of  intense of what My Doctor would have to get All of this Testing and thing’s I had and Medicare , Medicaid The Drug was  not approved yet by the FDA at the time and had to go threw several step’s since it was a New Drug that was very  possible would give Me a little time to get My Life in Order as My Cancer Stage 4 Melanoma.My Cancer Doctor had Me  and My Family at the Same time on a whole week of Testing knowing what he could even do other than to be Ready for  the New’s She can start at The Treatment today it was set up and I was the First to get this Drug from My Doctor and  Hospital. I had to just wait for a week the Place’s dent back to My Cancer Doctor he was sending Blood Sample’s and All  the Test and there were four Place’s that Had to agree to get started. I had to ask know is My Medicare and Medicaid  going to Approve All This since My Melanoma Cancer is at Stage Four. There again this was taken care of Start the Drug  for Melanoma My Doctor had Hospital Ready the Technician had to make the Drug as I was coming it had to be taken  fast as I arrived. No time to lose. I Pray that I and Doctor got this Drug to Other’s it is on FDA Approved and could help  other’s like Me to Live Longer. Please don’t start the same as alway’s if You are low income and Poor the TN State with  other’s that have started already had to change Low Income and Cut out Treatment’s for Life to be Death IN TN. So the  change of TN doing this New CUT IT never give Me or Other’s If I would really be A Person to get a chance to take these  New Drug‘s and how fast Medicare Medicaid Gave Me and Thousand’s In need. It did work and all Nodule’s made them  smaller that was 2014 it’s 2019 Still Stable just sitting there.Thank God for Medicare, Medicaid I could not have lived in  My Stage 4 Melanoma this Change is WRONG FOR TN there NOT thinking of Me or TN.They would not let Me get the  Drug’s Change it will cut TN sickest OUT If Melanoma start’s Again TN will Cut Us OUT?    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    98 Sincerely,  Ms. Linda Gentry  754 Lafollette Dr  Maryville, TN 37801‐7670 Lgentry492@gmail.com  99 Jonathan Reeve From: Sent: To: Subject: tdcrutcher5@everyactioncustom.com on behalf of Terri Crutcher Sunday, September 29, 2019 10:37 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal in TN   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans. Tennessee has a history of cutting thousands of residents off TennCare roles.    Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets these  services. The proposal could also cut back on core health care services like hospital care, without federal approval or  public notice, and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans. Over the past two years, TennCare cut off 200,000 children, the great majority of  whom were still eligible.  Health care coverage is an essential part of improving the health outcomes of Tennesseans.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Respectfully submitted,    Terri Crutcher, DNP, RN    Sincerely,  Ms. Terri Crutcher  309 Twin Hills Dr  Madison, TN 37115‐2246 tdcrutcher5@gmail.com  100 Jonathan Reeve From: Sent: To: Subject: jhscrs@everyactioncustom.com on behalf of Charlotte and James Sewell Sunday, September 29, 2019 6:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grants are too vague Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Charlotte and James Sewell  1027 Davidson Rd  Nashville, TN 37205‐1023 jhscrs@bellsouth.net  101 Jonathan Reeve From: Sent: To: Subject: tstovall18@everyactioncustom.com on behalf of Thomas Stovall Sunday, September 29, 2019 7:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Thomas Stovall  235 Burges Dr  Nashville, TN 37209‐3241  tstovall18@email.mmc.edu  102 Jonathan Reeve From: Sent: To: Subject: sethcooper@everyactioncustom.com on behalf of Seth Cooper Sunday, September 29, 2019 7:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    As a physician with 50 years of practice experience treating patients in Tennessee, I have seen the benefits of Tenn Care   insurance for the most vulnerable of our patients including children, the disabled and the poor among us.  This block  grant will decrease benefits and eligibility for this most  needy population of our fellow citizens, and put caps on services  that will decrease needed medical care.   Tenn Care should  expanded, at no cost to the tax payers of Tennessee, under  the Affordable Care Act, and not further restricted with this politically motivated block grant proposal. A huge block of  federal money would decrease accountability for services to individual patient, and create the perfect set‐up for  politicians to manipulate the money for projects other than patient care.  I have always treated patients without health  insurance, but the lack of health insurance is always a disaster for the patients,  their families, and all of us due to poor  outcomes, greatly increased costs, and increased  morbidity and mortality.      As a practicing physician in Tennessee, I strongly oppose the consideration of changing Tenn Care to a block grant, and  strongly encourage the expansion of Tenn Care under the Affordable Care Act for the benefit of our most vulnerable  citizens, and all of us.    Robert Seth Cooper, MD          Sincerely,  Dr. Seth Cooper  103 2311 Valley Brook Rd  Nashville, TN 37215‐2016 sethcooper@tnonc.com  104 Jonathan Reeve From: Sent: To: Subject: phwilliams2@everyactioncustom.com on behalf of Patricia Williams Sunday, September 29, 2019 11:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Patricia Williams  4301 Elkins Ave  Nashville, TN 37209‐3643 phwilliams2@comcast.net  105 Jonathan Reeve From: Sent: To: Subject: JSBarritt@everyactioncustom.com on behalf of Jim Barritt Sunday, September 29, 2019 11:53 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Jim Barritt  528 Charlie Russell Rd  Shelbyville, TN 37160‐6545 JSBarritt@gmail.com  106 Jonathan Reeve From: Sent: To: Subject: grbrown989@everyactioncustom.com on behalf of gary brown Monday, September 30, 2019 5:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposed to TennCare block grant   Dear Gabe Roberts,    I am opposed to the proposal that changes how Tennessee administers Federal Medicaid funds to a block grant.  The  proposal unnecessarily puts the most vulnerable Tennesseans at risk of substandard access to medical care.  The  possible cutback or elimination of many elements of Medicaid, such as physical therapy, hospice, transplant coverage,  and prescription drugs.      The waiver proposal is a profit incentive for the state to reduce care for the sickest and most vulnerable, children,  women, and the disabled, who can ill afford it.  Please do not go forward with this harmful waiver that would politicize  the Federal Medicaid program.    Sincerely,  Gary Brown        Sincerely,  Mr. gary brown  412 S David Ln  Knoxville, TN 37922‐3211 grbrown989@gmail.com  107 Jonathan Reeve From: Sent: To: Subject: kerimills@everyactioncustom.com on behalf of Keri Mills Monday, September 30, 2019 6:05 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Keri Mills  2440 Lawrenceburg Hwy  Lawrenceburg, TN 38464‐5903 kerimills@hotmail.com  108 Jonathan Reeve From: Sent: To: Subject: shaakir55@everyactioncustom.com on behalf of Shakura Kharif Monday, September 30, 2019 6:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Shakura Kharif  Nashville, TN 37211  shaakir55@gmail.com  109 Jonathan Reeve From: Sent: To: Subject: morrishambyiii@everyactioncustom.com on behalf of James Hamby III Sunday, September 29, 2019 9:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. James Hamby III  2841 Islington Dr  Murfreesboro, TN 37128‐7501 morrishambyiii@me.com  110 Jonathan Reeve From: Sent: To: Subject: kaysjanosik@everyactioncustom.com on behalf of Kay Janosik Sunday, September 29, 2019 9:36 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kay Janosik  331 Big Springs Rd  Bell Buckle, TN 37020‐4704 kaysjanosik@gmail.com  1 Jonathan Reeve From: Sent: To: Subject: tseador@everyactioncustom.com on behalf of Tom Seador Sunday, September 29, 2019 10:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I perform volunteer work with economically disadvantaged Tennesseans who either depend upon TennCare or are not  even covered by any healthcare plan.      I am opposed to the proposal to change Tennessee’s Medicaid TennCare plan into a “block grant.” I believe this proposal  would cause  harm and jeopardize coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tom Seador  Brentwood, TN 37027  tseador@yahoo.com  2 Jonathan Reeve From: Sent: To: Subject: jcole494@everyactioncustom.com on behalf of Janice Cole Sunday, September 29, 2019 10:22 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Janice Cole  907 S Brittain St  Shelbyville, TN 37160‐4605 jcole494@gmail.com  3 Jonathan Reeve From: Sent: To: Subject: mscordys@everyactioncustom.com on behalf of Cordula Carlton Sunday, September 29, 2019 10:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.     Please stop trying to hurt the uninsured and the children.    Sincerely,  Mrs. Cordula Carlton  1602 Birch St  Shelbyville, TN 37160‐3780 mscordys@charter.net  4 Jonathan Reeve From: Sent: To: Subject: Traviscarlconner@everyactioncustom.com on behalf of Travis Conner Sunday, September 29, 2019 10:19 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We urge you not to go forward with this harmful proposal.    Sincerely,  Travis Conner  210 A Berry Way  Seymour, TN 37865‐5916  Traviscarlconner@gmail.com  5 Jonathan Reeve From: Sent: To: Subject: ljrmlwcz@everyactioncustom.com on behalf of Linda Jarmulowicz Sunday, September 29, 2019 2:09 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Linda Jarmulowicz  1389 Vinton Ave  Memphis, TN 38104‐4866  ljrmlwcz@gmail.com  6 Jonathan Reeve From: Sent: To: Subject: marie.griffin@everyactioncustom.com on behalf of Marie Griffin Sunday, September 29, 2019 2:13 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Marie Griffin  1809 Laurel Ridge Dr  Nashville, TN 37215‐4808 marie.griffin@vanderbilt.edu  7 Jonathan Reeve From: Sent: To: Subject: josheverett93@everyactioncustom.com on behalf of Josh Everett Sunday, September 29, 2019 10:46 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Josh Everett  801 Village Hills Dr  Nashville, TN 37217‐3745 josheverett93@gmail.com  8 Jonathan Reeve From: Sent: To: Subject: tgarrettmoore@everyactioncustom.com on behalf of Tyler Moore Sunday, September 29, 2019 2:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Harmful TennCare Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     People with disabilities or necessary long‐term care shouldn't have to make medical decisions based on a dwindling  Medicaid account. The money should directly support those most vulnerable citizens and their doctors and loved ones  shouldn't have to check their pocketbook before deciding whether to take a medically necessary extended hospital stay  or hospice care .    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Tyler Moore  Memphis, TN 38117  tgarrettmoore@gmail.com  9 Jonathan Reeve From: Sent: To: Subject: lhardy103@everyactioncustom.com on behalf of Linda Hardy Sunday, September 29, 2019 11:12 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Linda Hardy  7245 Highway 70 S  Nashville, TN 37221‐2843 lhardy103@comcast.net  10 Jonathan Reeve From: Sent: To: Subject: robert.miller@everyactioncustom.com on behalf of Robert Miller Sunday, September 29, 2019 3:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Dr. Robert Miller  1500 21st Ave S Ste 3000 Nashville, TN 37212‐3139 robert.miller@vumc.org  11 Jonathan Reeve From: Sent: To: Subject: knilob@everyactioncustom.com on behalf of Bo Link Sunday, September 29, 2019 11:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Bo Link  5142 Regent Dr  Nashville, TN 37220‐1945 knilob@gmail.com  12 Jonathan Reeve From: Sent: To: Subject: Westtennmods@everyactioncustom.com on behalf of Heather King Sunday, September 29, 2019 3:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    My daughter will be one of the first hit and will suffer! She is very fragile. She depends on most available services and  equipment to live! This includes the very breaths she takes. She needs assistance for the very most basic needs including  feeding, breathing, and bathing. Because of the care and services she receives she is thriving! Without these services or  any cuts she will likely die! This is our real and daily struggle. This is not a joke! This is a real life situation that will impact  both my daughter and this family!   Sincerely,  Heather King    Sincerely,  Heather King  25145 Highway 18 N  Toone, TN 38381‐8927 Westtennmods@bellsouth.net  13 Jonathan Reeve From: Sent: To: Subject: lcrsell@everyactioncustom.com on behalf of Logan Sell Sunday, September 29, 2019 7:37 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mr. Logan Sell  119 Christmas Dr  Atoka, TN 38004‐2716  lcrsell@gmail.com  14 Jonathan Reeve From: Sent: To: Subject: eshaw@everyactioncustom.com on behalf of Elizabeth Weaver Sunday, September 29, 2019 1:40 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Elizabeth Weaver  4039 Hofburg St  Memphis, TN 38127‐4138  eshaw@southwest.tn.edu  15 Jonathan Reeve From: Sent: To: Subject: juleweed@everyactioncustom.com on behalf of Julie Kornman Sunday, September 29, 2019 11:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    HEALTH CARE IS A RIGHT OF EVERY PERSON IN THE UNITED STATES!    Sincerely,  Ms. Julie Kornman  4500 Heath Rd  Nashville, TN 37221‐6603  juleweed@gmail.com  16 Jonathan Reeve From: Sent: To: Subject: linnannguss@everyactioncustom.com on behalf of Linn Guss Sunday, September 29, 2019 7:50 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Linn Guss  114 Lee Ann Dr  Shelbyville, TN 37160‐6134 linnannguss@gmail.com  17 Jonathan Reeve From: Sent: To: Subject: kfjo@everyactioncustom.com on behalf of Kimberly Johnson Sunday, September 29, 2019 6:39 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     As a nurse at UT Medical Center, we encounter patient’s from all over East Tennessee due to the closure of many  smaller, rural hospitals. These patients must drive farther for treatment and DO NOT need coverage capped or denied  for life threatening illnesses for which they seek treatment. This is a dangerous and certainly deadly proposal.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Kimberly Johnson  608 Hidalgo Ct  Knoxville, TN 37923‐6089 kfjo@umich.edu  18 Jonathan Reeve From: Sent: To: Subject: jtaylor@everyactioncustom.com on behalf of Jerry Taylor Sunday, September 29, 2019 8:08 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     I know from personal experience ‐ both as a former state lawyer and as an advocate for TennCare/Medicaid program  enrollees, that the State of Tennessee and its officials cannot be trusted to do what is right to protect the vulnerable  population TennCare is designed to serve, while maintaining program integrity.  If anything, Tennessee needs greater  federal oversight ‐‐ rather than less oversight and more of what the State euphemistically calls "flexibility."     The block grant proposal is founded on self‐serving political motives of the Tennessee General Assembly, aided and  abetted by a first term governor who cannot or will not stand up to the pressure and do what is right for the  disadvantaged citizens of Tennessee.  The financially and medically disadvantaged citizens of Tennessee need and  deserve the protections in the Medicaid statutes and regulations.  I urge you to maintain these protections by rejecting  the Tennessee block grant proposal.         Sincerely,  Jerry Taylor  2000 Second Avenue 511 Union St Ste 2300 Nashville, TN 37219 jtaylor@burr.com  19 Jonathan Reeve From: Sent: To: Subject: MidoriBarstow@everyactioncustom.com on behalf of Midori Barstow Sunday, September 29, 2019 9:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Midori Barstow  MIDORI BARSTOW  Knoxville, TN 37919  MidoriBarstow@gmail.com  20 Jonathan Reeve From: Sent: To: Subject: Marietta Shipley Sunday, September 29, 2019 6:01 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***       This program may work for the persons presently covered, but IT TOTALLY IGNORES THE 675,000 PERSONS NOT  COVERED BY TENNCARE THAT ARE ELIGIBLE.  IT IS A COWARDS WAY OF DEALING WITH AN ISSUE THAT COULD EASILY BE  SOLVED BY GETTING EXTENDED TENNCARE AND AVOIDING THE CLOSING OF MANY RURAL TENNESSEE HOSPITALS AND  NOT COVERING TENNESSEE CITIZENS.  SHAME ON YOU!!!    *Seek Consensus     Find Solutions    Get Results*  The Mediation Group of Tennessee  Marietta Shipley  2809 Wimbledon Road  Nashville, Tennessee 37215  615 292‐6069   (F) 615 292‐7785  *www.mariettashipley.com*  21 Jonathan Reeve From: Sent: To: Subject: Susan Daniel Sunday, September 29, 2019 5:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grants in Tennessee   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Please don't switch out Tenncare to block grants, it would be a downgrade for our citizens. Expand Medicaid instead, it's  the better choice m  22 Jonathan Reeve From: Sent: To: Subject: Sarah Hunt Sunday, September 29, 2019 2:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant for TN   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Tennesse doesn't need a block grant to meet the health needs of Tennesseans.  This state needs to expand Medicaid to  provide insurance for over 600,000 uninsured Tennesseans.  This number includes over 200,000 children.    Years of not expanding Medicaid has been a disgrace to and disregard for fellow Tennesseans who deserve more from  their state.  Those blocking this expansion should be ashamed and those trying to plug the dike with a bandaid will live  to regret this poorly devised plan.    A Concerned Citizen  23 Jonathan Reeve From: Sent: To: Subject: Crystal Colter Sunday, September 29, 2019 2:14 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Concerned about block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am concerned about the proposal to turn Medicaid into a block grant proposal, as I believe this will risk the coverage  and endanger the health of too many TN citizens, including and perhaps especially the disabled community.     I do not support the block grant proposal.     Crystal Colter  1304 Dunbarton Dr.  Maryville, TN   24 Jonathan Reeve From: Sent: To: Subject: Kirk Smith Sunday, September 29, 2019 12:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposition to block grants     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  We need to provide health care in a systematicconsistent manner. Block grants are rife with opportunities for misuse, as  the grantees may or may not ever actually deliver medical services‐ they could be startups that fail, and the $ is gone.  We have seen this happen in other arenas‐ child welfare, for example, where facilities closed without serving a single  child. Not one. The only way to guarantee medical services is to cover individuals and let them choose a provider and  obtain medical care.      Sent from my iPhone  25 Jonathan Reeve From: Sent: To: Subject: David Twiggs Sunday, September 29, 2019 4:26 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  A set amount of money each year is not taking care of the needs of Tennesseans. Nor will it adequately cover the costs  of Tennessee hospitals and/or nursing homes. People who won’t get care will die because of this plan if adopted.    Sent from my IPhone  David Twiggs  My Phone # ‐ 865‐986‐6899  Cell Phone # ‐ 865‐300‐2154  dtwiggs2@gmail.com                              26 Jonathan Reeve From: Sent: To: Subject: Diane Keeney Saturday, September 28, 2019 4:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] reject the block grant proposal and expand Medicaid   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   The Governor’s block grant proposal does nothing to provide coverage for 675,000+ Tennesseans without any health insurance. It also risks benefits and coverage for current Medicaid enrollees.    The real solution is for the legislature to expand Medicaid.     Kindly,  Diane    1603 Stokes Ln  Nashville, TN  37215-1511  27 Jonathan Reeve From: Sent: To: Subject: Joseph Saturday, September 28, 2019 3:54 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Feedback regarding the TN Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I want to give my voice to the discussion regarding the TN Block Grant. As an autistic adult, it is most likely that what is being proposed would virtually eliminate needed services, and it would have a devastating effect, on my health and wellbeing. Joseph Galbraith Hixson, TN   To help protect y ou r priv acy , Micro so ft Office prev ented au tomatic download of this pictu re from the Internet. A v ast logo   This email has been checked for viruses by Avast antivirus software.  www.avast.com       28 Jonathan Reeve From: Sent: To: Subject: awalton@everyactioncustom.com on behalf of Anna Walton Friday, September 27, 2019 3:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     The proposal does nothing to address the real healthcare crises in our state such as rural hospital closures and the  Medicaid coverage gap.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Anna Walton  211 7th Ave N  Nashville, TN 37219‐1823  awalton@tnjustice.onmicrosoft.com  29 Jonathan Reeve From: Sent: To: Subject: johnorze@everyactioncustom.com on behalf of John Orzechowski Friday, September 27, 2019 4:07 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” As you know, TennCare is a vital safety net for some of the  state's most vulnerable residents ‐ people with disabilities, older adults who need long‐term care, low income families,  and more. The program ensures these individuals have access to coverage for health and financial security, and supports  the health care infrastructure we all depend on.     This block grant proposal would cause immense harm and jeopardize coverage for these vulnerable Tennesseans. This  proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services. It would give  the state the ability to restrict services like physical therapy, hospice, and transplant coverage without normal federal  oversight – and arbitrarily limit who gets them. The proposal could also cut back on core health care services like  hospital care, without federal approval or public notice, and exclude coverage of high‐cost prescription drugs. I fear that  the people with the greatest need (e.g. people who need long‐term care to be safe in their community, children with  special needs) will suffer the most under this proposal, since their care is the most costly.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  I respectfully urge you not to go forward with this harmful proposal.    Sincerely,  John Orzechowski  549 Croley Dr  Nashville, TN 37209‐1762  johnorze@yahoo.com  30 Jonathan Reeve From: Sent: To: Subject: keilaf@everyactioncustom.com on behalf of Keila Franks Friday, September 27, 2019 4:39 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs. I work with clients who need high levels of care, and the  provisions in the proposal about reducing the amount of services someone can receive is highly concerning. Under this  proposal, people who need the most services are the ones who will bear the brunt of any reductions.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Ms. Keila Franks  510 Gay St Apt 616 Nashville, TN 37219‐1240 keilaf@gwmail.gwu.edu  31 Jonathan Reeve From: Sent: To: Subject: cheardley@everyactioncustom.com on behalf of Christine Eardley Saturday, September 28, 2019 11:08 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comment Opposing Medicaid Block Grant Proposal   Dear Gabe Roberts,    I am opposed to the proposal to radically change Tennessee’s Medicaid partnership with the federal government by  converting federal funding for TennCare into a “block grant.” This proposal would cause immense harm and jeopardize  coverage for vulnerable Tennesseans.     Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get  vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new  authority to cut services for these vulnerable populations. The state could eliminate or restrict services like physical  therapy, hospice, and transplant coverage without normal federal oversight – and arbitrarily limit who gets them. The  proposal could also cut back on core health care services like hospital care, without federal approval or public notice,  and exclude coverage of high‐cost prescription drugs.     TennCare needs more accountability, not less. The state should not be allowed to make changes to the Medicaid  program without federal oversight or eliminate federal standards, which are in place for the protection of patients.  Without such guardrails, the state could return to the days when managed care contractors failed to provide care to  patients and providers were left unpaid. This proposal invites fraud and abuse and threatens the availability of vital  health coverage for Tennesseans.     As someone who works with the elderly on a daily basis, assisting them in applying for Tennessee Medicaid, I cannot  emphasize enough how badly Tennessee Medicaid is needed to cover our most vulnerable citizens. The Medicaid  program should be expanded. There is a desperate need to cover as many of our TN citizens as possible, particularly for  wellness visits, If we address and prevent medical conditions from worsening by expanding Medicaid coverage. This  would allow more people access to medical treatment and medications, saving cost for more extensive treatment in the  future.    This waiver is fundamentally flawed and cannot be fixed. It goes against the goals and purpose of the Medicaid program.  We respectfully urge you not to go forward with this harmful proposal.    Sincerely,  Mrs. Christine Eardley  103 Shadydale Dr  Hendersonville, TN 37075‐4411 cheardley@comcast.net  32 Jonathan Reeve From: Sent: To: Subject: Pat Cooper Saturday, September 28, 2019 1:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  We are totally against the TennCare Block Proposal. It would hurt our most vulnerable and those in need. Let’s try to  help!!! No other state has such a program and that should tell us something.  Charlie and Pat Cooper     Sent from my iPhone  33 Jonathan Reeve From: Sent: To: Subject: Fran Rajotte Saturday, September 28, 2019 1:32 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I am totally against the block grant.  It would take an unconscious person to approve this especially in light of the fact  that no other state is doing it.  We are very concerned about those on TN care and Medicaid.  My grandsons are  students and on TNCare and I do not want our governor to mess with their health insurance.  Can we ever do what’s  best for the good of the people?    Giv. Lee is a huge disappointment to us on several levels.  We do not want this block grant to occur!    Fran Myers    Sent from my iPhone  34 Jonathan Reeve From: Sent: To: Subject: carol Fox Saturday, September 28, 2019 11:48 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To whom it may concern:    I am writing to voice my concern about the effects of the proposed medical block grant.    I have a charming 5‐year‐old granddaughter who has multiple disabilities. Her care, tube feeding, therapists and  orthotics are costly, but are making a tremendous improvement in her life.    Block grants will be disastrous for her and children like her. Does the State of Tennessee expect the cost of medications,  therapists and medical care to stay at today's level? Those costs will rise by leaps and bounds, just as they have been  doing. Each year, more of the state's neediest and most vulnerable will be lopped off the list of those served and face a  future without health insurance and without the care they need.    Why not provide affordable healthcare for those in need instead of a limited annual grant?    My granddaughter will perhaps be served by the Katie Beckett Waiver, if those in charge do not write the requirements  in ways to exclude her. However, the waiver is untouchable for only three years. After that, disabled and medically  fragile children in Tennessee will again be at the mercy of those who would throw those children and their families into  limbo once more.    Please do better, Tennessee. Take care of those who most need help. That can't be achieved through block grants.    Thank you,  Carol Fox  5 Northvale Court  Johnson City, TN 37604    c.graham.fox@gmail.com  35 Jonathan Reeve From: Sent: To: Subject: Ann Strange Saturday, September 28, 2019 10:27 AM PUBLICE NOTICE TENNCARE [EXTERNAL] No to block grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I am writing to express my opposition to block grants to provide healthcare to Tennessee citizens. Block grants are not  flexible and I do not have faith in the Tennessee government to provide benefits that are required to the most  vulnerable of Tennessee citizens. I fear they will reduce the number and amount of benefits, and provide an excuse to  limit benefits. The state government says it will provide more flexibility and creativity in providing services and I believe  that is false. There is no basis or history to support that. Medicare and TennCare already need more support from the  federal government. Do not use our state as a means to cut benefits to those most in need.    Ann Strange  307 Lake Forest Drive  Knoxville, TN 37920  strangersrus@gmail.com  36 Jonathan Reeve From: Sent: To: Subject: Michelle Miller Saturday, September 28, 2019 2:24 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant Proposal - Public Comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   My representative, Jim Cooper has informed his constituents that this Block Grant Proposal does nothing to provide coverage for 675,000+ Tennesseans without any health insurance. It also risks benefits and coverage for current Medicaid enrollees. As a current Medicaid enrollee, I am very concerned that this grant will take away my coverage, or decrease my benefits. I have many health problems. I cannot afford to lose health coverage.     No other state is pursuing this dangerous plan. So why is Tennessee? I'm beginning to believe that Tennessee does not care about its poorer citizens. It's time to prove me wrong.     Warm regards,     Michelle Miller   Nashville, TN 37214    Currently Reading  To help protect y ou r priv acy , Microsoft Office prev ented automatic download of this pictu re from the Internet. Book Cov er Get your own email signature    “Never forget what you are, for surely the world will not. Make it your strength. Then it can never be your weakness. Armour yourself in it, and it will never be used to hurt you.” ~George R.R. Martin, A Game of Thrones True Book Addict Castle Macabre The Christmas Spirit Michelle Stockard Miller, Writer Seasons of Reading Gather Together and Read Hosting a reading challenge or event? Share it here: Sleep Less, Read More Facebook group  37 Jonathan Reeve From: Sent: To: Subject: Joanne Beckham Friday, September 27, 2019 7:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] We oppose changing TennCare to a block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   By refusing to expand Medicaid, Tennessee has lost billions of dollars in federal reimbursements. Now the state stands to lose more by switching to a fixed dollar  block grant, instead of being reimbursed for the full cost of Medicaid (TennCare) spending in the state.    Under current TennCare funding, federal contributions to the state increase with the number of people covered and the rise in enrollees’ health and long‐term care  costs. Block grants are a fixed amount that may not keep pace with the program’s growth in health care costs. That would be especially true during an economic  downturn or a pandemic.    Tennessee could only save money with a block grant if it eliminates programs, refuses to expand coverage for the poorest Tennesseans, and cuts payments to  providers. In that case, low‐income people might go without needed care or postpone treatment, resulting in higher rates of preventable hospitalizations, expensive  emergency room visits, even unnecessary deaths.    For all those reasons and more, we oppose changing TennCare funding to a block grant and urge the state to expand Medicaid instead.    Sincerely,  Joanne and Roger Beckham  413 Manor View Lane  Brentwood, TN 37027  38 Jonathan Reeve From: Sent: To: Subject: Terri Clouse Friday, September 27, 2019 6:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I would like to register with you that I am STRONGLY opposed to this block grant.     Far, far better to just expand Medicaid. I sincerely do not understand the opposition   to Medicaid expansion.     As a taxpayer, I urge you to reconsider.     Thank you,  Terri Clouse  615‐354‐4191  ‐‐   Terri Clouse  614‐404‐5587  terri.bell.clouse@gmail.com    39 Jonathan Reeve From: Sent: To: Subject: Rose Willeford Friday, September 27, 2019 6:24 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I am opposed to this solution.  We need to expand Medicaid so more people can get coverage.  We have a lot of  vulnerable Tennesseans, they need coverage.  I work in healthcare and things cannot continue as they have been.      Thank you,   Rosemarie Willeford   37220    Sent from my iPad  40 Jonathan Reeve From: Sent: To: Subject: Jan Dunn Friday, September 27, 2019 5:58 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medical Coverage for those struggling in Tennessee   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Governor Lee, please encourage the State Legislators to expand Medicaid to cover thousands of Tennesseans in need of  adequate medical coverage.    Jan Dunn  1012 Thyme Court  Brentwood, TN 37027  41 Jonathan Reeve From: Sent: To: Subject: Melba Walker Friday, September 27, 2019 5:49 PM PUBLICE NOTICE TENNCARE [EXTERNAL]   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   The block grant proposal ignores the reality of 675,000 Tennesseans without health coverage. Further the block grant  design ultimately risks coverage of those currently covered. There's a reason NO OTHER state is trying this. The proper  course of action is to EXPAND MEDICAID as most other states have done. Under this proposal we will dig a hole so deep  we can never get out of it.   42 Jonathan Reeve From: Sent: To: Subject: mailagent@thesoftedge.com on behalf of extemporaneously@hotmail.com Friday, September 27, 2019 4:00 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Dear Director:    I am writing in response to the Division of TennCare's Amendment 42 aimed to change the funding structure of  Tennessee's Medicaid program. I am part of a network of advocates that work directly with TennCare beneficiaries as  well as Tennessee's uninsured population.    As you are aware, consumer advocacy organizations both local and national have expressed grave concern over the  potential these changes will have on eligibility, access to life‐saving services, and the deep rooted health inequities  among people in poverty, non‐Caucasian populations, and others who experience discrimination in health care.     .    Amendment 42 does not provide adequate information about how Tennesseans will be protected from discrimination,  how Tennessee plans to improve health outcomes, or the state's plan to improve access to care among Tennessee's  uninsured population.    Simply put, Amendment 42 is asking for an unprecedented amount of trust with too little details and no established  oversight system in place.    Respectfully,    Jose Davila  1903 Manila Ave  Memphis, TN 38114‐1744   43 Jonathan Reeve From: Sent: To: Subject: Shana Watson Friday, September 27, 2019 8:33 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant   To Whom It May Concern:    I am the parent of a child with severe disabilities and this sort of thing just really is upsetting. Tennessee is the last state  to finally implement a Katie Beckett waiver and now there are going to be more limitations and stipulations added. This  is incredibly unfair and frustrating. Our household income is not low enough to get help most of the ways it is available  so this is a Godsend & now maybe it won’t even help my child. He requires diapers for life, formula for life, he’s in a  wheelchair, and will always need to be cared for. Please do not do this to the families who are desperately needing help.    Sincerely,  Shana Watson    Sent from my iPhone  44 Jonathan Reeve From: Sent: To: Subject: Linda Pearce Friday, September 27, 2019 1:56 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grants     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I think block grants are unwise for Medical coverage for Tn.  llp  45 Jonathan Reeve From: Sent: To: Subject: Janeen Bradley Pennell Friday, September 27, 2019 1:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 Comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   To Whom It May Concern:    Changing the current Medicaid system to a block grant system will harm Tennesseeans. Many will lose access to vital  healthcare, prescriptions, and programming, and will be unable to properly expand the program should the need arise.    Please consider the following as taken from the TN Disability Coalition's website:  How could the block grant impact Tennesseans with disabilities:  The CHOICES long-term supports and services for adults with disabilities and seniors who do not have access to Medicare are included in the block grant. Block grant funding will make it hard to expand services or serve additional people.  The Employment and Community First CHOICES long-term supports and services program is included in the block grant. Block grant funding will make it hard to expand services or serve additional people.  New programs, including the Katie Beckett Program, will not be included in the block grant for their first three years of operation. At that time, the funding that the program has needed for operations (whether or not enrollment is at full capacity) will be the funding allotted for the future of the program through the block grant. Block grant funding will make it hard to expand services or serve additional children.  Tennessee is asking to be exempt from future federal Medicaid mandates. This means, for example, that if the federal government mandated that states cover a particular medication or provide a new type of service, Tennessee would be exempt from that rule and not have to do so.  Tennessee is currently required to cover all prescription medications included in the federal Medicaid drug rebate program. The state is asking to adopt a commercial-style closed prescription drug formulary. This could limit prescriptions covered, in particular specialty medications needed by a small group of people, like those of us with disabilities.  The federal Medicaidid comparability requirement means that covered benefits must be the same for all covered populations. Tennessee is asking to waive this requirement, which would allow TennCare to vary the types of benefits that are available to different types of patients. This could prevent an individual beneficiary from accessing the types of services he or she needs.  Tennessee is asking to never have to reapply or have TennCare re-evaluated by the federal government. This would remove oversight of the program. Federal oversight has traditionally been critical to protecting people with disabilities.  Tennessee is asking to be able to make changes to the benefits it provides, TennCare enrollment processes and service delivery systems without federal government approval or oversight. Federal oversight has traditionally been critical to protecting people with disabilities.   Please make an attempt to understand how these proposed changes will have a detrimental, if not deadly, effect on our fellow Tennesseeans.     As a person without disability, it is unfathomable to me that we would seek to enact legislation that could harm our most vulnerable populations. I cannot imagine these stress, the mental and physical pain that those with disabilities would face if this block grant moves forward.     No cost-saving measure is worth the price if that price is the suffering of another fellow human being.     Do better.  46   Best regards,    Janeen Bradley Pennell             47 Jonathan Reeve From: Sent: To: Subject: Ashlee Carmack Friday, September 27, 2019 1:02 PM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grants     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  To Whom It May Concern,   I am a disabled TennCare recipient and I oppose block grants to fund our TennCare program. I am concerned at the lack  of federal oversight and guidelines as I think all medications and conditions should be covered. I’m very concerned that  my expensive subcutaneous HyQvia infusions will no longer be covered as I have read that speciality drugs may be cut in  order to save money. Without my infusions for Common Variable Immunodeficiency, I am sick constantly, require  antibiotics, steroids and hospitalizations. These infections can be fatal and cause permanent organ damage as well as  antibiotic resistance. My infusions have very literally been a lifesaver for me and I can’t imagine having to try to live  without them. Please reconsider block grants as I do not feel that they are in the best interest of Tennessee’s citizens  with disabilities, myself included.   Thank you,   Ashlee Carmack    Sent from my iPhone  48 Jonathan Reeve From: Sent: To: Subject: terryingreenacr@aol.com Friday, September 27, 2019 11:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Against Block Grants   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   No to block grants  Pro:   Expansion of Medicaid in Tennessee  The taxes Tennesseans pay into the federal coffer should come back to us.  It is that simple.  Terry Livingston  7941 Blueberry Rd  Powell, TN  37849  ‐‐  Sent from myMail for Android  49 Jonathan Reeve From: Sent: To: Subject: Valerie Crawford Friday, September 27, 2019 9:16 AM PUBLICE NOTICE TENNCARE [EXTERNAL]   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Accepting these block grants will put thousands of Tennesseans at risk medically. Please don't do this.   50 Jonathan Reeve From: Sent: To: Subject: Frank Meeuwis Friday, September 27, 2019 8:29 AM PUBLICE NOTICE TENNCARE [EXTERNAL] OPPOSE AMENDMENT 42   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   My name is Frank Meeuwis of Madison, TN 37115. I am a person with disability, and a family with two young boys. I oppose the block-granting (Amendment 42) of Medicaid funds in Tennessee because I have fear of people losing coverage, losing benefits, and I fear the lack of traditional Federal oversight. In no uncertain terms, I opposed Amendment 42 and turning Tennessee’s Medicaid fundingto a block grant! Thank you, Frank Meeuwis 51 Jonathan Reeve From: Sent: To: Subject: Tim Jerome Friday, September 27, 2019 8:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Opposition to the TN BLock Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   As a parent of a special needs daughter with severe handicaps and CP I oppose the Block Grant Proposal as it will make it difficult to expand services and funding for children such as my daughter in the future. Without Federal oversight protection, the program could be disbanded or cut, as we already have experienced a reduction in nursing care hours, despite our doctor's protests and our appeal before a judge. This could easily and more readily happen again under the Block Grant Proposal, so I am saying NO to this. Thank you for attending to my comment and concerns. Tim and Erica Jerome 63 Rolling Links Blvd, Oak Ridge, TN 37830 Phone 865-585-2353 52 Jonathan Reeve From: Sent: To: Subject: Frank Meeuwis Friday, September 27, 2019 8:13 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Deeply concerned...   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   My name is Frank Meeuwis of Madison, TN 37115.  I am a person with disability, and a family with two young boys.  I oppose the block‐granting (Amendment 42)  of Medicaid funds in Tennessee because I have fear of people losing  coverage, losing benefits, and I fear the lack of traditional Federal oversight.  Specifically;  • Amendment 42 does not guarantee coverage for Tennessee’s uninsured. Tennessee will  still not receive federal dollars already designated to provide health insurance for working  Tennesseans who earn too much for TennCare and not enough for ACA plans.  • Amendment 42 would permit Tennessee to cut or limit optional benefits and place additional limits on mandatory  benefits without federal approval.  • Amendment 42 authorizes Tennessee to limit benefits and/or target certain populations.  This has the potential to deepen health inequities among people who are in poverty, who  are non‐Caucasian, and/or people who experience other discrimination in health care.    Again, in no uncertain terms, I opposed Amendment 42 and turning Tennessee’s Medicaid funding into a so‐called block  grant!    Thank you,  Frank Meeuwis    Sent from Mail for Windows 10    53 Jonathan Reeve From: Sent: To: Cc: Subject: Donna Ellstrom Thursday, September 26, 2019 2:00 PM PUBLICE NOTICE TENNCARE sen.becky.massey@capitol.tn.gov [EXTERNAL] block grant for tenncare     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I have reservations about the block grant proposal:    1.  The Tenncare representatives who spoke September 24 at Westmorland in Knoxville, TN, reported that Tennessee  does better than other states in running the Medicaid program financially efficiently.  The savings that Tennessee is able  to attain come from administrative efficiency and not from patient care.    Then, with the block grant Tennessee expects to operate efficiently and continue to save money, but with the  grant Tennessee would benefit from the savings because those savings would be shared equally by our state and the  federal government.  However, administrative costs are one of the exclusions of items not to be covered in the modified  block grant.  THAT MEANS THAT SAVINGS HAVE TO COME FROM PATIENT CARE!  Either participants are going to suffer  or the savings will be far less than hoped for by the proponents of the modified block grant.    2.  Tennessee wants to be relieved from “unnecessary federal interventions.”  I am sure there is redundant paperwork,  but I am also aware that accountability comes with oversight from another entity.  Lack of federal interventions could  lead to sloppy or even hurtful administration of the program.    3.  I remember the promise from the state when mentally ill were released to the streets of Knoxville (with the closing of  Lakeshore) that money from the state would follow the patients and that they would continue to get care, just in a  different way.  That did not happen.  I have trouble trusting that Tennessee will follow through in a compassionate way  for the people who live on the margins of our society.    Donna Ellstrom  dellstrom510@att.net  3622 Laurel Oak Lane  Knoxville, TN  37931  54 Jonathan Reeve From: Sent: To: Subject: lj hoke Thursday, September 26, 2019 11:32 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenncare recidivism   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Just accept the ACA and take the money.  Anything less is a needless excursion in cutting of one's own nose for  whatever indistinct reason.    55 Jonathan Reeve From: Sent: To: Subject: Floor ScrapeAustin Javes Wednesday, September 25, 2019 4:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenncare block grant I fully oppose the idea of using block grants from the Federal Government to fund the State's Medicaid program. As I read the reasons for implementing this idea I saw over and over again how it was going to save money but doesn't really say how except that Tennessee knows how to run the system better and more efficiently without interference from the Federal Government. I find this hard to believe considering this is a State that loses children in its Child Services program! This is a State that haphazardly denies people coverage with its Tenncare program, and then sometimes lets them back in with no apology or explanation. No, the State has no record of running things better without any oversight. Also, you're addressing the wrong problem with is that the healthcare system is broken. That is what you need to correct. Hospitals and doctors grossly overcharge with no oversight at all. Hospitals are closing throughout the State because they are not making enough profit. The healers no longer run the system, only the financiers. It's a travesty! You need to regulate the healthcare system so that healthcare is available to everyone not meted out so some politician can brag that some money has been saved while people suffer. 58 Jonathan Reeve From: Sent: To: Subject: Ellen Finney Thursday, September 26, 2019 7:34 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I strongly oppose funding Medicaid using a block grant. I feel that this idea is poorly thought out and will put  out health care system at risk. Our inexperienced governor has proposed this plan without the background to  understand its consequences. Expanding Medicaid would be much more effective in improving the health of  our state.    Ellen Finney  Franklin  59 Jonathan Reeve From: Sent: To: Cc: Subject: Ada Shannon Wednesday, September 25, 2019 3:48 PM PUBLICE NOTICE TENNCARE Jamie O'Neal; Tim Howell [EXTERNAL] Amendment 42 Feedback   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Good Afternoon,    As an employee of a Provider of HCBS in many Rural areas of East Tennessee and as a private  citizen of Tennessee, I would like to share my questions and thoughts regarding the Block  Draft and the TennCare CHOICES program.  I have tried to reference the sections and memos I  am referring to below.    My first question is whether the DRAFT language highlighted in blue below is stating that the  State will work on infrastructure (community and individual) to support mandatory EVV  Compliance?  (See Draft language)    Providers are being told that mandatory confirmation is non‐compliant (See Memo Language),  and that MCOs will determine if Providers will be paid for hours served with “limited”  exceptions.    The majority of the manual confirmations that our company encounters are for Rural  Clients.  Quite often they do not have working internet service, or cellular service.  Sometimes,  they don’t even have a working telephone, or a phone at all, or the phone is lost or not  charged.  Sometimes they will not allow their phone to be used by anyone visiting their home.    Providers have not had reimbursement rate increases despite ever‐increasing expenses.  It  seems the MCC’s have had incentives at their level that have not been shared with Providers.  **    **(From the Block Grant Draft) “This new financing model emphasizes state accountability for  effective program management, because any shared savings earned by the state will be based  directly on the state’s performance in delivering high‐quality, cost‐effective care to its  members, while also incentivizing performance and ensuring that financial responsibility for  Tennessee’s Medicaid program continues to be equitably shared between the state and the  federal government.  In essence, Tennessee is asking the federal government to hold it to a  similar standard as that to which Tennessee holds its managed care organizations—to assume  61 responsibility for the risk of managing care, with corresponding financial incentives to reward  efforts to reduce costs, improve quality, and improve outcomes.”   These financial incentives  have stopped short of the Providers who are finding it harder to sustain serving CHOICES  clients with each year that passes.  Many have already dropped off the list of Providers for this  reason.    The exact parameters of when these hours that are manual confirmations will be reimbursed  needs to be shared.  If these hours are served by the Provider and not reimbursed, then  Providers will have no choice but to stop serving those clients.  As I said before, the majority of  these are Rural clients.      This plan to not reimburse Providers will not support rural health transformation, improve  access to care or improve the quality of care for these members.  In fact, it does the opposite  and guarantees those members will not receive the services they need at all.  Providers should  be reassured in writing that they will not shoulder this penalty.  This memo seems at cross  purposes with the language of the Block Grant proposal.  Which does the State of Tennessee  support?        BLOCK GRANT DRAFT LANGUAGE     Leveraging Medicaid as a Catalyst to Promote Rural Healthcare Transformation     Healthcare for patients in rural communities across the United States remains an enduring  challenge.  This challenge is magnified in disproportionately rural states like Tennessee.  In  many rural states, Medicaid is uniquely positioned to provide leadership for rural health  transformation initiatives as the largest statewide payer (other than Medicare) with member  and provider relationships in all areas of the state.       DRAFT  September 2019    15      Under the proposed demonstration, the state will have the flexibility to strategically invest  block grant funds to support rural health transformation efforts intended to either improve  access to care for members in rural communities or improve the quality of care those  members receive.  This could include working with healthcare providers to support the  adoption of technologies to overcome some of the traditional challenges associated with  ensuring patient access to up‐to‐date specialist care (e.g., electronic consultation,  telemedicine).  This could also include working with providers in rural communities to develop  and implement new payment and service delivery models that incentivize value and outcomes 62 to drive improvements in both individual and population health, while ensuring that the cost  of care is sustainable for healthcare providers, their communities, and the state.  One  significant challenge to the sustainability of the cost of care in many rural communities is the  expense of infrastructure required by current regulations; with additional flexibility to support  rural health transformation efforts, the state could help support the transition of facilities to  more sustainable, community‐appropriate models.        MEMO LANGUAGE      To: Home and Community Based Providers in CHOICES and Employment and Community First  CHOICES that are Required to Use an Electronic Visit Verification (EVV) System   From: Jamie O’Neal, Assistant Deputy Chief of Programs, Contracts, and Compliance   Date: March 31, 2019   Subject: MANDATORY Electronic Visit Verification Compliance    Manual confirmation is NOT an electronic form of verification and is NOT COMPLIANT.  TennCare will be working with MCOs and with providers to determine whether there are  limited exceptional circumstances in which a visit may be manually confirmed and remain  eligible for reimbursement, and if so, the documentation that will be required in order for such  payment to be provided. This will likely include only instances in which there are EVV system  or device issues beyond the provider’s control, and which would require documentation,  review, and approval by an MCO prior to payment. Each such instance would be reported to  TennCare, tracked, and subject to further review and investigation as appropriate. Further  information on this topic is forthcoming.      Thank You,            Ada Shannon   63 Jonathan Reeve From: Sent: To: Subject: Martha Shepard Tuesday, September 24, 2019 7:49 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant for TNCARE To Whom It May Concern,  It is very difficult to comment on what I have read so far on the TNCARE Block Grant proposal  because not much has been said about how the state can deliver the care for less.  The only thing I have seen is clerical  savings. It has been stated in the papers   by the state administration that the Block Grant will not cover more people, so what is the purpose of doing it?  The  newspapers have stated that the state may get up to $1B in savings but there has not been a definite stated use of that  money.   Let's have some more specifics.   Thank‐you, Martha Shepard      ‐‐   Martha Shepard  204 McCreary Hts.  Dickson, TN 37055  615-446-9782 H  615-330-0419 C  64 Jonathan Reeve From: Sent: To: Subject: GEORGE NEELY Tuesday, September 24, 2019 9:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Mr. Gabe Roberts;  I am writing to you today concerning the Governor’s plan to change TennCare from its current shared payment system  to a block grant system. According to what I have read in the news the main reason for going to a block grant system is  to allow the Tennessee government the ability to manage and change the type and amounts of care TennCare patients  receive and to facilitate some kind of savings for the state and federal governments. I see no real justification for  removing CMS from the formula that is working and see no clear plan to achieve savings. The Governor only points to  one minor problem with the current system, 600 TennCare fraud convictions for doctor shopping to get opioids in the  past four years, which equates to 150 convictions per year which is .0107% of the 1.4 million enrollees. The governor  believes these people should be eliminated from TennCare eligibility as punishment but under the current TennCare  rules cannot be disqualified. First as I have pointed out this is a very small percentage of the total population and no  significant savings would be achieved. Second as reported in all the news media these people are victims of an opioid  epidemic caused by big pharma companies like Perdue Pharmaceutical. I think the fact that the current system requires  they be allowed to continue coverage recognizes these people are victims with a medical problem that needs to be  treated and if they were removed from the system would have nowhere to go for help. Other than this I see no way to  save money other than to cut services mandated by the federal government. The question is, are the mandated services  beneficial for the citizens of Tennessee? These are the services:  Inpatient hospital services, Outpatient hospital services  ,EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services; Nursing Facility Services ,Home health  services, Physician services, Rural health clinic services, Federally qualified health center services ,Laboratory and X‐ray  services ,Family planning services, Nurse Midwife services, Certified Pediatric and Family Nurse Practitioner services,  Freestanding Birth Center services (when licensed or otherwise recognized by the state), Transportation to medical care,  Tobacco cessation counseling for pregnant women. I think all of these are important services so why would the governor  what to remove them? Clearly removing them would save money in the short run but could cost money and lives in the  long run? Where and how is this plan going to save, that is the question that is not answered?  The current system is working. There have not been any requests from TennCare recipients, which I am aware of, to  change the current system. I fear that like the states refusal to accept Medicaid expansion which cost the state and its  population greatly this too is a plan for disaster.  To sum up I use and old axiom; if it ain’t broke, don’t fix it.  Respectfully; George Neely  gjneely@comcast.net  615‐419‐3305  P.S. I am the parent of two adult children on TennCare  65 Jonathan Reeve From: Sent: To: Subject: Debora Ramos Tuesday, September 24, 2019 4:42 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Amendment 42 comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   As a parent of an autistic child that has Tenncare, I realize that this amendment more than likely will have negative  affects on his healthcare. These are a few of the issues I find with the block grant proposal.  1. Has there been a study completed on how the block grant will disproportionately affect children/adults with  disabilities? Probably not because the focus of this amendment is solely on rationing and cuts.  2. Nothing in this amendment mentions the possible effect that rationing and cuts will have on the healthcare of  children. Will parents forego doctors visits, dental care, etc because they simply can no longer afford it?   3. Tennessee already has some of the highest rates of uninsured citizens and rural hospital closures? This block grant  proposal does NOTHING to lower either of these rates!  4. Have the Tenncare problems that resulted in the mass unenrollment of 220,000 children due to the outdated 98 page  application package through mail/fax, wrong addresses, and simply unprocessed applications been fixed? No, of course  they haven't. They have barely scratched the surface.  5. How are you going to exempt administrative expenses from the ending of the TN state contributions but not children  or senior citizens?!!!!!!  6. Relying on the CBO projections that normally require several revisions to the variation of inflation rates to establish  grant amounts? This has to be fixed.  7. Risking the health of senior citizens, children and the disabled to champion fiscal conservatism especially when there  is federal money available is morally corrupt. Frankly this is what Bill Lee and his cronies are trying to do.   66 Jonathan Reeve From: Sent: To: Subject: ALLISON MOORE Saturday, September 21, 2019 3:47 PM PUBLICE NOTICE TENNCARE [EXTERNAL] DO NOT ADOPT THE MEDICAID BLOCK GRANT   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I want to go on record as being against the Medicaid block grant proposal. Governor Lee - do what you were elected to do and protect ALL your constituents, but please even more those most vulnerable! This block grant is a Medicaid cut in disguise and we are not fooled. This will effect the most vulnerable citizens, including people with pre-existing conditions and disabilities! Our state costs will go up and there will be rising health care costs for the growing numbers of elderly Tennesseans who need help to pay higher prescriptions drug prices - this will fall on the state eventually. Medicaid cuts will happen year after year. Saving money will require the state to cut services to those with the most expensive healthcare needs, critically ill children, frail seniors and people with pre-existing conditions. These changes will jeopardize patient safety at nursing homes, essential services for critically ill babies and children and access to opioid addition treatment. The nation's most respected patient advocacy groups oppose block grants as a threat to patients and the Washington Post warned that Tennessee is about to sabotage its own health care system. DO NOT ADOPT THE MEDICAID BLOCK GRANT IN OUR STATE! Allison Moore allison.mom61@gmail.com 100 Cavalcade Circle, Franklin TN 37069 67 Jonathan Reeve From: Sent: To: Cc: Subject: Jim Ullrich Friday, September 20, 2019 2:11 PM PUBLICE NOTICE TENNCARE sen.richard.briggs@capitol.tn.gov; rep.martin.daniel@capitol.tn.gov [EXTERNAL] comments on health care block grants proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Since there hasn’t been published any information about how the cost savings are obtained now it is difficult to make a  judgement if the proposal will be an improvement or not. The data I have seen indicates that the State of Tennessee  would be classified as having an  unhealthy population and as far as I know is not improving. It is closer to the bottom  than the top of the pile.  Since the goal of any health program should be the improvement of the health of the  population and I have not heard of that being the goal of the new proposal I have great concerns if this is a step forward.  It seems to me the only difference is now we don’t  share in the financial benefits of the cost efficiencies and have less  say in how the money is spent. The problem with making costs the only  benchmark is from a cost standpoint the most  efficient thing to do is nothing. In my lifetime I have seen many companies regret that path taken since it seems to end  up a race to the bottom and cost shifting rather than savings. There seems to me there is no certainty in how or where  the so called extra money would be spent such as expansion (which will be needed  to improve  from unhealthy to  healthy population) or benefits (promises of the same for current but what about the future participants) or whatever.    Since I consider the present method to be a failure this proposal doesn’t seem to move the needle much in the direction  of a healthier population or no one has shown how that would happen. I would suggest a proposal with a goal of  improving the health of our population. Establish a current baseline. Use measurable benchmarks including costs for  improvement. This type of proposal I think would bring certainty to who who benefits and spread it out to participants,  taxpayers , and the system without identifying it at the beginning. What’s working, what’s needed, what’s affordable in  what areas to meet the goal of better health for us would be possible without spelling it out or making promises in the  beginning as times will change. The sharing  of cost or savings from 0% to 90% could be based on improving health, risks,  and  amount of control by state. I admit that I do not know how to accomplish or implement such a proposal but there  are plenty of people in this state that do. Maybe the process needs to be less top down particularly if the top’s main  concern is costs.    Jim Ullrich  541 English Village Way  Apt 817   Knoxville, TN 37919  865‐670‐2886       69 Jonathan Reeve From: Sent: To: Subject: Nathan Friday, September 20, 2019 1:33 PM PUBLICE NOTICE TENNCARE [EXTERNAL] NO TENNCARE BLOCK GRANT PLAN   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Stop trying to kill poor people!   70 Jonathan Reeve From: Sent: To: Subject: Yvonne Perret Friday, September 20, 2019 10:21 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid block grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I'm writing to submit a public comment about Tennessee's Medicaid block grant proposal. Although I live in Maryland, I have family that lives in Tennessee. As a social worker for the past 50 years, I have worked with low-income individuals and families, especially those who have serious mental illness and co-occurring disorders with substance use. Over the past 25 years, I have focused on people who are homeless and who have serious mental illness. Having a plan that potentially eliminates benefits along with a plan not to comply with formulary requirements is a perfect storm. One of the important lessons I have learned over the years is that limiting access to care, however it is couched in other language, leads to more severe illness, greater levels of poverty, and poorer health outcomes. I question how thee valuation will be performed regarding health care outcomes, for example. Will individuals be asked? How many? Or will only data from providers be utilized, data that often does not unmask the true experiences of those receiving care. It seems to me, in the years that I've worked, that states continue to try to reduce costs without comprehensively assessing the total impact of how cost reduction affects people's lives. Can we offer more effective services and analyze costs? Of course, but we must be cautious in this analysis. Typically the people receive Medicaid have multiple problems that include ongoing serious physical health problems, mental health challenges, poverty, unstable or poor housing, underemployment, lack of access to safe and reliable transportation, lack of health and other education, wraparound services that take into account all their health needs, holistic assessments of all family members, and a need for early identification and intervention. I believe states need to take into account these social determinants of health and focus on addressing such needs over time. Given that, currently, the Federal government is providing a higher percentage match to Medicaid expansion states under Medicaid, this is the time to think creatively and holistically. Block grants don't do that. Thank you. Yvonne M. Perret, MA, MSW, LCSW-C Yvonne M. Perret, MA, MSW, LCSW-C Executive Director, Advocacy and Training Center 1116 Bedford St. Cumberland, MD 21502 301-777-7987 (phone and fax) 240-500-0786 (cell) "In the end, tyrants fall. Think of it. Always"--Gandhi   ‐   71   72 Jonathan Reeve From: Sent: To: Subject: WANDA POJAR Thursday, September 19, 2019 12:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant "governor", DO YOUR JOB and take care of the ones who have no ability to care for themselves. You live on your millions and you have everything you could possibly need, as does your family. That's not the case for many, through NO fault of their own. DO YOUR JOB and stop this mess you're considering. 73 Jonathan Reeve From: Sent: To: Subject: Rachel Walden Thursday, September 19, 2019 5:59 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid block grant - public comment   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I oppose the plan to implement Medicaid block grants in Tennessee. This plan incentivizes the state to limit enrollment  and coverage for vulnerable Tennesseans. Our state is already poorly ranked for access to care and health outcomes ‐  block grants will only worsen this problem. Tennessee should instead implement ACA‐related Medicaid expansion and  work to increase coverage for as many of our residents as possible.     Furthermore, the public input process is inadequate. Three public hearings are not enough in a state the geographic size  of Tennessee, and major population centers such as Chattanooga and the Tri‐Cities are completely ignored. The closest  public hearing location to my home is more than one hundred miles away. That hearing takes place at 2:30 pm on a  weekday, when people will be at work or school, a schedule that works to further reduce the public’s ability to engage in  person. It is disrespectful to propose such massive changes to this public program while severely limiting the public’s  access to ask questions and provide feedback in person.     Rachel Walden         74 Jonathan Reeve From: Sent: To: Subject: Christopher McCarter Thursday, September 19, 2019 4:28 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Could we make enrollment for single men less stringent?  Also can we do something about the illegals of any  origin obtaining it?  I do know spanish and I have heard them say they have it.  “Tengo Tenncare, es gratis”  which means “I have Tenncare it is free”.    75 Jonathan Reeve From: Sent: To: Subject: Lisa Conklin Thursday, September 19, 2019 1:11 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐      I want to go on record as being against the Medicaid block grant proposal. Governor Lee ‐ do what you were elected to  do and protect ALL your constituents, but please even more those most vulnerable! This block grant is a Medicaid cut in  disguise and we are not fooled. This will effect the most vulnerable citizens, especially people with pre‐existing  conditions, which is, face it ALL OF US! Our state costs will go up and there will be rising health care costs for the  growing numbers of elderly Tennesseans who need help to pay higher prescriptions drug prices ‐ this will fall on the  state eventually. Medicaid cuts will happen year after year. Saving money will require the state to cut services to those  with the most expensive healthcare needs, critically ill children, frail seniors and people with pre‐existing conditions.  These changes will jeopardize patient safety at nursing homes, essential services for critically ill babies and children and  access to opioid addition treatment. The nation's most respected patient advocacy groups oppose block grants as a  threat to patients and the Washington Post warned that Tennessee is about to sabotage its own health care system    DO NOT ADOPT THE MEDICAID BLOCK GRANT IN OUR CITY!      76 Jonathan Reeve From: Sent: To: Subject: Lee Ann Photoglo Thursday, September 19, 2019 12:18 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   ATTN: Governor Lee: I want to go on record as being against the Medicaid block grant proposal. Governor Lee - do what you were elected to do and protect ALL your constituents, but please even more those most vulnerable! This block grant is a Medicaid cut in disguise and we are not fooled. This will effect the most vulnerable citizens, especially people with pre-existing conditions, which is, face it ALL OF US! Our state costs will go up and there will be rising health care costs for the growing numbers of elderly Tennesseans who need help to pay higher prescriptions drug prices - this will fall on the state eventually. Medicaid cuts will happen year after year. Saving money will require the state to cut services to those with the most expensive healthcare needs, critically ill children, frail seniors and people with preexisting conditions. These changes will jeopardize patient safety at nursing homes, essential services for critically ill babies and children and access to opioid addition treatment. The nation's most respected patient advocacy groups oppose block grants as a threat to patients and the Washington Post warned that Tennessee is about to sabotage its own health care system! DO NOT ADOPT THE MEDICAID BLOCK GRANT IN OUR CITY!   Lee Ann Photoglou  Nashville Citizen  Tax Payer  Property Tax Payer  Resident of Forest Hills              77 Jonathan Reeve From: Sent: To: Subject: Susan MEADOR Thursday, September 19, 2019 10:54 AM PUBLICE NOTICE TENNCARE [EXTERNAL] public comment on Medicaid block grant proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I want to go on record as being against the Medicaid block grant proposal. Governor Lee - do what you were elected to do and protect ALL your constituents, but please even more those most vulnerable! This block grant is a Medicaid cut in disguise and we are not fooled. This will effect the most vulnerable citizens, especially people with pre-existing conditions, which is, face it ALL OF US! Our state costs will go up and there will be rising health care costs for the growing numbers of elderly Tennesseans who need help to pay higher prescriptions drug prices - this will fall on the state eventually. Medicaid cuts will happen year after year. Saving money will require the state to cut services to those with the most expensive healthcare needs, critically ill children, frail seniors and people with pre-existing conditions. These changes will jeopardize patient safety at nursing homes, essential services for critically ill babies and children and access to opioid addition treatment. The nation's most respected patient advocacy groups oppose block grants as a threat to patients and the Washington Post warned that Tennessee is about to sabotage its own health care system DO NOT ADOPT THE MEDICAID BLOCK GRANT IN OUR CITY! Susan Meador 522 Clematis Drive Nashville, TN 37205 6156-351-9948 s.meador@comcast.net 78 Jonathan Reeve From: Sent: To: Subject: Tom and Missy Horesh Thursday, September 19, 2019 10:43 AM PUBLICE NOTICE TENNCARE [EXTERNAL] No Block Grants     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  To Whom It May Concern,    I’m writing to recommend that TN not be the first state in the US to try block grants.  Block grants will pull even more  sick and poor Tennesseans off of TennCare.  So many families struggle getting healthcare due to the financial hurdles.   Please don’t make it worse just to please Trump.      Please NO BLOCK GRANTS.    Expand Medicaid to help people.      Thank you,  Missy Horesh  Brentwood, TN 37027  79 Jonathan Reeve From: Sent: To: Subject: Sonia Hardin Thursday, September 19, 2019 10:11 AM PUBLICE NOTICE TENNCARE [EXTERNAL] TennCare Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   The proposal mentioned cutting TennCare for people who also have Medicare.  Would this impact the elderly population  who has Medicare but also TennCare who are in long‐term care facilities? I would be afraid that there are many elderly  long‐term care residents who are able to live in these facilities because TennCare helps support the cost.    Thanks    Sonia A. Hardin, RN, Chief Compliance Officer  Chota Community Health Services  4798 New Highway 68  Madisonville, TN 37354  423-442-2622  fax: 423-442-5760  shardin@chotahealth.org    The Secret of Change Is to Focus All of Your Energy, Not on Fighting the Old, But on Building the New Socrates    CONFIDENTIALITY NOTE: The information transmitted, including attachments, is intended only for the person(s) or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and destroy any copies of this information.   80 Jonathan Reeve From: Sent: To: Subject: JeffLeston Thursday, September 19, 2019 9:44 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments on Block Grant- fraud reduction   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   The block grant waiver that the State proposes should also include the  provision for the State to keep the proceeds of  fraud reduction. Right now, in the open‐ended funding methodology, there is little or no incentive for the State to  pursue fraud, as 2/3 of any recoveries must be sent back to the Federal Treasury under current rules.  If the State is  willing to limit the risk to Federal taxpayers and take on the increased risk of fraud, it stands to reason that the proceeds  of that effort should accrue to TennCare.      Using the GAO’s own estimates each 1% of fraud reduced is $10 Million that can accrue to the State.    Jeff Leston      81 Jonathan Reeve From: Sent: To: Subject: MARY OGLE Thursday, September 19, 2019 4:57 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant - NO! Medicaid expansion - YES!   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Medicaid block grant - NO! Medicaid expansion - YES! Tennessee residents have paid Federal taxes but are being denied what they are entitled to in return - give them the Medicaid expansion they paid for and from which they are entitled to receive benefits!! Mary Ogle 3776 Carnes Memphis, TN 38111 82 Jonathan Reeve From: Sent: To: Subject: Zella Cunningham Wednesday, September 18, 2019 8:46 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Simple   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   In language the average citizen can understand, How will Medicare/Medicaid health coverage change in Tennessee if the block grant goes into effect? Zella Cunningham Chattanooga,TN "In happy moments, praise God. In difficult moments, seek God. In quiet moments, worship God. In painful moments, trust God."     Virus-free. www.avg.com     83 Jonathan Reeve From: Sent: To: Subject: linda shelton Wednesday, September 18, 2019 6:17 PM PUBLICE NOTICE TENNCARE [EXTERNAL] I have a 27 year   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***    old grandson who had seizures when he was born which left his many brain cells dead his mother also has a bipolar son  and she is in need of psychiatric help herself Aya grandmother of this family have five degenerative herniated bulging  disc MN m I disabled please don't hurt this family with this block grant idea it will probably only help the wealthy        Sent via the Samsung Galaxy, an AT&T 4G LTE smartphone  84 Jonathan Reeve From: Sent: To: Subject: Kristen Stewart Wednesday, September 18, 2019 4:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block Grant Proposal   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Dear Mr. Roberts,  I am concerned that the Medicaid block grant proposal does not address the pressing need of Tennesseans who are  underinsured or completely uninsured. With our health care system in crisis, instead of experimenting with a new plan, I  would prefer we pursue expanding Medicaid to use federal money to serve more of our fellow Tennesseans.   As a taxpayer, it grieves me to read that states that have expanded Medicaid are seeing a decreased rate of fatality. This  is a way we can save lives.  Thank you for your consideration.  Kristen M. Stewart  3909 Cambridge Avenue  Nashville, TN 37205  85 Jonathan Reeve From: Sent: To: Subject: Margaret Richardson Wednesday, September 18, 2019 1:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicare block grant proposal     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  This block grant request is a terrible idea for Tennessee citizens.  Our health care in Tennessee is very borderline as it is  with rural hospitals closing and fewer citizens who have insurance coverage.  A block grant will just add a layer of red  tape to the citizens needing care and the only ones who will benefit are the block grant administrators.  Please do not  allow it to happen.    Sent from my iPad  86 Jonathan Reeve From: Sent: To: Subject: TEENA COHEN Wednesday, September 18, 2019 12:41 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Public comment on block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Mr. Gabe Roberts, Director: Sept. 18, 2019 My first response to the article with further details regarding the potential block grant for TN relates to one of the dates selected for public hearings. The day mentioned in the Tennessean article is Oct.1 at Family and Children's Service location. That date is poorly chosen, as it is the second day of Rosh Hashanah, the Jewish New Year. I do believe we are all citizens of TN, no matter our religious faith, and this date selected is not respectful of members of the Nashville/Middle TN Jewish community. As I have read the "fine print" of what is known at this time related to the block grant being considered, I am totally against this approach to the healthcare of the most needy and vulnerable among us!! What is being promoted is to "save" money, which appears to translate to the reality of cutting back on services for TennCare clients and limiting the number of clients allowed into the program. The article in today's Tennessean states, "Among these exclusions are care provided to individuals with intellectual disabilities, children in state custody and patients who are dually enrolled in TennCare and Medicare." Additionally, "the plan excludes TennCare's prescription drug costs, uncompensated care payments to hospitals and administrative costs incurred throughout the program." While I consider myself to be somewhat informed on local issues, it is still baffling to me that our 'Volunteer' state of TN did not make the wise choice to expand Medicaid when the opportunity was present!! Funds to our state would have helped to better the lives of those needing this program without huge exceptions as are evident in the block grant option. 87 Thank you for listening/reading, Teena Cohen Nashville, TN 37205 88 Jonathan Reeve From: Sent: To: Subject: Valerie Werne Wednesday, September 18, 2019 11:25 AM PUBLICE NOTICE TENNCARE [EXTERNAL] The Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  OK, so we know about how it will be funded. What we really want to know is what changes and how medicaid is going to  implement the new changes. The changes, to be implemented by the medicaid\Tncare, is the main concern for the  citizens. In today's society, you have the low income(or no income}, whom of course will be impacted by the changes  and the middle income, whom are already paying their portion and can't afford an increase in the cost of their  healthcare. The draft of the proposal concludes that there will not be any changes that will impact the care, the  community is already receiving, if so, then how do they propose to make this work? If all of the specifics are not defined  in the proposal how can one make an informed decision?  It is good that we know that our lawmakers are moving toward making things better in the way of healthcare, and we  appreciate that effort.  Please look at all of the facts first.  To prevent the needs that are go great, implement more education in teaching ,our future population, on how to live a  healthy life via way of healthy eating, exercise and removal of contaminants of our supply of foods in which we provided  the population with to feed themselves.    ‐‐  Valerie Werne  89 Jonathan Reeve From: Sent: To: Subject: Connie Watkins Wednesday, September 18, 2019 9:31 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicaid Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   This plan is still not going to help the uninsured or uninsurable population.  We have many who are forced to start their  retirement at age 62 for various reasons but have no insurance until age 65 and have no affordable options; people who  work for companies who offer insurance but it takes half their paycheck to pay the premium; people who have  insurance but the deductibles are so high, they never meet them, so their insurance really is not beneficial; people  unable to work and applying for disability or needing healthcare to get healthy so they can go back to work. The  Affordable Care Act helped many people but there and still hoards of people who it still leaves out in the cold.     Thank you for your time and I appreciate your patience in reading this.    Sincerely,     Connie Watkins   90 Jonathan Reeve From: Sent: To: Subject: LinoreAH Wednesday, September 18, 2019 8:03 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenncare Block Grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Hello,    I am writing in regards to the Block Plan proposal for Tenncare/Medicare. It is unconscionable and irresponsible to give  both the state and federal government the incentive to cut costs on a program that covers our most vulnerable children.  Governer Lee claimed that no child would lose coverage, but said nothing about the quality of that coverage. If high‐cost  items are cut to save money, children will suffer and die. No amount of money is worth that.    Thank you,  Linore Huss  Kingsport, TN 37660  91 Jonathan Reeve From: Sent: To: Subject: xmundt Wednesday, September 18, 2019 2:04 AM PUBLICE NOTICE TENNCARE [EXTERNAL] Medicare Block Grant Proposal.     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐    To whom it may concern;    I see that y'all are trying to implement medicare as a block  grant.   I strongly urge you NOT to vote for this change.   The fact is  that this change will negatively impact many Tennesseans, by cutting coverage for vital services and medications, and  likely raising the costs for all of us.      Vote NO on the Block Grant scheme!      Dave mundt    1066 Indian Ridge Road    Blaine,  TN  37709    92 Jonathan Reeve From: Sent: To: Subject: Evan Rehm Tuesday, September 17, 2019 9:23 PM PUBLICE NOTICE TENNCARE [EXTERNAL] do not support TennCare block grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  I do not support the TennCare block grant. This will ultimately lead to lower funding for TN as the government will most  likely not put up additional funds during the pending recession. Please do not support this application for the block grant   Evan Rehm  Clarksville TN    93 Jonathan Reeve From: Sent: To: Subject: Holt, Berry Tuesday, September 17, 2019 7:50 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Tenncare Block Grant     *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown  senders or unexpected email ‐ STS‐Security. ***      ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Cutting 125,000 vulnerable people from the Tenncare roles was a first step in a tragic pattern. A block grant program will  further erode the health safety net for the most vulnerable. This is a political stunt appealing to budget hawks but  expanding Tenncare is the right answer for people.  Bill Lee is a rich  man who runs with other rich men. Please use some humility and look at this like a less fortunate man  trying to take care of his family and only hearing the rich man talk about a system the rich man never participates in. The  arrogance of the Republican majority and Bill Lee is a  recipe for human suffering.    E. Berry Holt  Bradley Arant Boult Cummings, PLC  Roundabout Plaza, Suite 700  1600 Division Street  Nashville Tennessee, 37203  615.252.2312 (O)  615.351.3905 (C)    ________________________________    Confidentiality Notice: This e‐mail is from a law firm and may be protected by the attorney‐client or work product  privileges. If you have received this message in error, please notify the sender by replying to this e‐mail and then delete  it from your computer.    94 Jonathan Reeve From: Sent: To: Subject: Tammy Sisco Tuesday, September 17, 2019 6:44 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   I have read the article from the Tennessean it seems like a new and better approach to me. Something really needs to  be done. At least governor Lee is trying to make changes for the better   95 Jonathan Reeve From: Sent: To: Subject: JD Peery Tuesday, September 17, 2019 3:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Public comment re: TennCare block grant   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Just expand Medicaid, you fucking blowhards  96 Jonathan Reeve From: Sent: To: Subject: Thomas Hensley Tuesday, September 17, 2019 3:03 PM PUBLICE NOTICE TENNCARE [EXTERNAL] health insurance   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Every consumer and taxpayer in Tn is subsidizing insurance for others, whether they have coverage for themselves or not. We all know that government worker's insurance is subsidized by the taxpayer. We should also be aware of the fact that employers who subsidize insurance for their workers get a partial tax credit, then recoup the rest of their money from the consumers, for employers do pass that cost on to the consumers, and the employee who receives the subsidy pays no tax on the benefit. We have a lot of dolts receiving those benefits, then calling their benefactors freeloaders. Some pay more than others, but there are absolutely no freeloaders when it comes to insurance. It is past time to find a way to cover those who are subsidizing everyone else. It is also the right thing to do. 97 Jonathan Reeve From: Sent: To: Subject: Helen Harris Tuesday, September 17, 2019 2:15 PM PUBLICE NOTICE TENNCARE [EXTERNAL] Comments TennCare Block Grant Importance: High   *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. ***   Helen Harris 4785 Cloister Cove Memphis, TN 38118 901-368-6005 I have comments about Tenncare block grant. A block grant is a bad idea. Government should not decide what medication or treatments would be cover. We hope that this idea is not accepted. Why not bring back the TennCare Spenddown Program for a year for people with disabilities that have large medical bills. The income is too high to qualify for TennCare. We face hardship and unable to get some medications or medical treatments. We need help and cannot go to the emergency room. Doctor tells me to go to the emergency room for chest pain that I often have, but I cannot pay all those medical bills and household bills for a place to live. Therefore, I just stay home in the bed hurting so bad I have to hold chest bending over until I can make it to the bed to lay down. My husband is on over 20 medications. I am on over 20 medications. Not counting diabetes supplies, CPAP supplies, oxygen supplies, and nebulizer supplies. I am under 13-doctor care and refused to see anymore specialist. My husband is under seven doctor and just recently found out his kidneys are bad. We need assistance with medical bills.    98 Jonathan Reeve From: Sent: To: Subject: abpaine@aol.com Wednesday, October 9, 2019 9:10 PM PUBLICE NOTICE TENNCARE Re: [EXTERNAL] Block grant Medicaid Jonathan, Thanks so much. yes, please send me scheduling details. Meanwhile my comments: I am opposed to the block grant proposal - siding with the criticism that many health professionals (doctors and nurses) have given at previous hearings on the proposal. This is no way to take care of the health needs of the poor and disenfranchised in Tennessee. We are on a slippery slope with this. Thanks so much, Anne Paine 6412 Brownlee Drive Nashville, TN 37205 615-202-6053 -----Original Message----From: PUBLICE NOTICE TENNCARE To: abpaine Sent: Thu, Oct 3, 2019 8:52 am Subject: RE: [EXTERNAL] Block grant Medicaid Good morning, Ms. Paine. You may send any comments you have about the block grant proposal to this email address. If you would prefer to mail your comments, you may send them to-Gabe Roberts, Director Division of TennCare 310 Great Circle Road Nashville, TN 37243 In addition, we are hosting a hearing in Jackson, Tennessee, today (Thursday, October 3) at which individuals may offer spoken or written comments on the proposal. The hearing will be held in the Program Center of the Jackson-Madison County Library, located at 433 East Lafayette Street. The hearing is scheduled to begin at 2:30 p.m. Central Time. TennCare is also in the process of scheduling additional hearings in Memphis and Chattanooga. Those hearings will likely take place during the work week of October 14-18. I would be glad to share the scheduling details of those hearings with you as soon as they are available, if that would be helpful. Jonathan Reeve Assistant Director of Policy Division of TennCare, Policy Office 310 Great Circle Rd., Nashville, TN 37243 p. 615-507-6449 -----Original Message----From: abpaine Sent: Tuesday, October 1, 2019 9:03 PM To: PUBLICE NOTICE TENNCARE Subject: [EXTERNAL] Block grant Medicaid *** This is an EXTERNAL email. Please exercise caution. DO NOT open attachments or click links from unknown senders or unexpected email - STS-Security. *** 1 ---------------------------------------------------------------------Please tell me how to submit a comment on the proposal for block grant Medicaid funding. Thanks so much. Anne Paine Nashville Tn 37205 Sent from my iPhone 2