Opinion ID: 786208
Heading Depth: 2
Heading Rank: 2

Heading: Plaintiff Hamby's Application Process

Text: 18 In 1995, Hamby, then sixty-one years old, was treated for skin cancer and testicular cancer. Hamby applied for TennCare coverage in December of 1995. Because Hamby had not yet received a response from the TennCare Bureau regarding his December 1995 application, Hamby completed and mailed a second application to the Bureau in February of 1996. 19 On his applications, Hamby stated that he had not been turned down for a health insurance policy other than Medicaid or Medicare. The TennCare Bureau denied both of Hamby's applications. The TennCare Bureau sent Hamby a written notice, dated March 20, 1996, which provided in part: 20 THIS IS WHY WE THINK YOU DO NOT QUALIFY FOR TENNCARE. 21 Your [February 1996] application was received after the end of an open enrollment period. 22 . . . . 23 If you or someone in your family has lost or cannot get health insurance because of a medical condition, fill in the attached appeal form and return it to us. You and your family members may qualify for TennCare because you are uninsurable. Uninsurable people can enroll in TennCare at any time. 24 . . . . 25 There are three ways to qualify for TennCare. We only checked one way. You may also be eligible if you are uninsurable (you lose or cannot get health insurance because of a medical condition you have) or if you qualify for Medicaid. 26 . . . . 27 REMEMBER! Even if you are not eligible for TennCare or Medicaid... you can apply later if the facts about you change. 28 (J.A. at 211-12.) 29 In June of 1996, Hamby sent a third application to the TennCare Bureau, in which he indicated that he had been denied health insurance. Hamby's third application was received by the TennCare Bureau on June 12, 1996. The TennCare Bureau later informed Hamby that he was enrolled in the program effective June 12, 1996. 30 In June of 1997, Hamby filed an appeal and declaratory ruling requesting that his enrollment relate back to the date of his original application in December of 1995. On June 12, 1998, the Administrative Law Judge (the ALJ) issued an order finding Hamby eligible for TennCare coverage based on his second application submitted in February of 1996. The ALJ reasoned that the Commissioner was required to open TennCare enrollment during the first three months of each calender year until enrollment reached 95% of the enrollment cap applicable for that year, and that Hamby had filed his February 1996 application during the open enrollment period of that year, when the total enrollment was less than 85% of the maximum enrollment of 1.5 million. 31 On September 4, 1998, the Commissioner's designee reversed the ALJ's order. The designee concluded that Hamby's enrollment date should have been based on his third application of June 12, 1996 because Hamby responded on his December 4, 1995 and February 15, 1996 applications that he had never been denied other medical insurance. The designee also concluded that Hamby's first two applications were submitted after enrollment for coverage as an uninsured person was closed. Hamby did not appeal or request for a hearing concerning the denial of his December 1995 and February 1996 applications.