SENATE BILL 1372
By Watson
HOUSE BILL 651
By Williams
HB0651
001446
- 1 -
AN ACT to amend Tennessee Code Annotated, Title 56
and Title 71, relative to health care.
WHEREAS, the General Assembly finds that since 2012 TennCare payments to
healthcare providers generally reimburse twenty-eight percent through thirty-four percent less
than Medicare; and
WHEREAS, the General Assembly requires TennCare to incentivize better access to
quality health care in rural and underserved communities; and
WHEREAS, recent federal regulations allow states to increase Medicaid payments for
many services to up to the average commercial rate to enable Medicaid plans to compete with
commercial plans when building provider networks; and
WHEREAS, it is prudent that, within the next twelve months, the Bureau of TennCare
develop a plan that identifies a variety of approaches, including increasing payment rates for
healthcare providers to parity with average commercial contracting rates, improving outreach
and problem resolution to providers, reducing barriers to provider credentialing and contracting,
providing for improved or expanded use of telehealth, and improving the timeliness and
accuracy of processes such as claim payment and prior authorization, and submit the plan to
the General Assembly for consideration during the following legislative session; now, therefore,
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
SECTION 1. Tennessee Code Annotated, Title 56, Chapter 7, Part 1, is amended by
adding the following as a new section:
(a) As used in this section:
- 2 - 001446
(1) "All-products clause" means a provision in a written or oral network
provider agreement between a health insurance entity and a healthcare provider
that requires the healthcare provider, as a condition of participation or
continuation in a provider network or health benefit plan to:
(A) Participate in another provider network that is utilized by the
health insurance entity and affiliated with the health insurance entity; or
(B) Provide healthcare services under another plan or product
offered by the health insurance entity;
(2) "Commissioner" means the commissioner of commerce and
insurance;
(3) "Health insurance entity" has the same meaning as defined in § 56-7-
109; and
(4) "Healthcare provider" means:
(A) A physician acting within the scope of a valid license issued
pursuant to title 63, chapters 6 or 9;
(B) A nurse acting within the scope of a valid license issued
pursuant to title 63, chapter 7 and who has a certificate to practice as an
advanced practice registered nurse issued by the board of nursing under
§ 63-7-126; or
(C) A physician assistant acting within the scope of a valid license
issued pursuant to title 63, chapter 19.
(b) A health insurance entity shall not:
(1) Offer to a healthcare provider a network provider agreement or
otherwise condition the healthcare provider's network participation based on an
all-products clause;
- 3 - 001446
(2) Enter into a network provider agreement with a healthcare provider or
otherwise condition the healthcare provider's network participation based on an
all-products clause; or
(3) Amend or renew an existing network provider agreement previously
entered into with a healthcare provider so that the network provider agreement
as amended or renewed adds or continues to include an all-products clause.
(c) If a network provider agreement contains a provision that violates this
section, or if a health insurance entity otherwise conditions a healthcare provider's
network participation based on an all-products clause, such provision or condition is void
and the commissioner shall assess the health insurance entity a civil penalty of ten
thousand dollars ($10,000) for each occurrence.
(d) On or before July 1, 2026, the commissioner shall promulgate rules to
effectuate this section. The rules must be promulgated pursuant to the Uniform
Administrative Procedures Act, compiled in title 4, chapter 5.
SECTION 2. Tennessee Code Annotated, Title 71, Chapter 5, Part 23, is amended by
adding the following as a new section:
(a) As used in this section:
(1) "All-products clause" means a provision in a written or oral network
provider agreement between a MCO or health insurance entity and a healthcare
provider that requires the healthcare provider, as a condition of participation or
continuation in a provider network or a health benefit plan to:
(A) Participate in another provider network that is utilized by the
MCO or health insurance entity and affiliated with the MCO or health
insurance entity; or
- 4 - 001446
(B) Provide healthcare services under another plan or product
offered by the MCO or health insurance entity.
(2) "Bureau" means the bureau of TennCare;
(3) "Commissioner" means the commissioner of finance and
administration;
(4) "Health insurance entity" has the same meaning as defined in § 56-7-
109;
(5) "Healthcare provider" means:
(A) A physician acting within the scope of a valid license issued
pursuant to title 63, chapters 6 or 9;
(B) A nurse acting within the scope of a valid license issued
pursuant to title 63, chapter 7 and who has a certificate to practice as an
advanced practice registered nurse issued by the board of nursing under
§ 63-7-126; or
(C) A physician assistant acting within the scope of a valid license
issued pursuant to title 63, chapter 19; and
(6) "Managed care organization" or "MCO" means an appropriately
licensed health insurance entity contracted with the bureau to manage the
delivery of, provide for access to, contain the cost of, and ensure the quality of
specified covered medical and behavioral benefits to TennCare enrollees through
a network of qualified providers.
(b) An MCO shall not:
(1) Offer to a healthcare provider a network provider agreement or
otherwise condition the healthcare provider's network participation based on an
all-products clause;
- 5 - 001446
(2) Enter into a network provider agreement with a healthcare provider or
otherwise condition the healthcare provider's network participation based on an
all-products clause; or
(3) Amend or renew an existing network provider agreement previously
entered into with a healthcare provider so that the network provider agreement
as amended or renewed adds or continues to include an all-products clause.
(c) If a network provider agreement contains a provision that violates this
section, or if an MCO otherwise conditions a healthcare provider's network participation
based on an all-products clause, such provision or condition is void and the
commissioner shall assess the MCO a civil penalty of ten thousand dollars ($10,000) for
each occurrence.
(d) On or before July 1, 2026, the commissioner shall promulgate rules to
effectuate this section. The rules must be promulgated pursuant to the Uniform
Administrative Procedures Act, compiled in title 4, chapter 5.
SECTION 3. Tennessee Code Annotated, Title 71, Chapter 5, Part 23, is amended by
adding the following as a new section:
(a) This section is known and may be cited as the "TennCare Provider Remedy
Plan."
(b) As used in this section:
(1) "Bureau" means bureau of TennCare;
(2) "Department" means the department of finance and administration;
(3) "Health insurance entity" has the same meaning as defined in § 56-7-
109;
(4) "Healthcare provider" or "provider" means:
- 6 - 001446
(A) A physician acting within the scope of a valid license issued
pursuant to title 63, chapters 6 or 9;
(B) A nurse acting within the scope of a valid license issued
pursuant to title 63, chapter 7 and who has a certificate to practice as an
advanced practice registered nurse issued by the board of nursing under
§ 63-7-126; or
(C) A physician assistant acting within the scope of a valid license
issued pursuant to title 63, chapter 19;
(5) "Managed care organization" or "MCO" means an appropriately
licensed health insurance entity contracted with the bureau to manage the
delivery, provide for access, contain the cost, and ensure the quality of specified
covered medical and behavioral benefits to TennCare enrollees through a
network of qualified providers;
(6) "Secret shopper survey" or "survey" means a research methodology
where callers who do not identify themselves as evaluators pose as enrollees
trying to schedule an appointment with a healthcare provider to evaluate
appointment wait time availability and the accuracy of healthcare provider
directories; and
(7) "TennCare" has the same meaning as defined in § 71-5-2503.
(c) The bureau shall establish and enforce appointment wait time standards and
the accuracy of healthcare provider directories by implementing a regular secret shopper
survey to determine each MCO's compliance with the standards in subsections (e) and
(f).
(d) An MCO is in compliance with the standards established in subsection (e)
when secret shopper survey results reflect a rate of appointment wait time availability
- 7 - 001446
within the standard time frame of at least ninety percent (90%). The bureau shall
determine if appointments offered via telehealth may be counted toward compliance with
appointment wait time availability standards.
(e) The bureau shall establish wait time availability standards for routine
appointments for the following services, if covered in an MCO's contract, and within the
specified limits:
(1) For outpatient mental health and substance use disorder services,
adult and pediatric appointment wait times must be no longer than ten (10)
business days from the date of request;
(2) For primary care services, adult and pediatric appointment wait times
must be no longer than fifteen (15) business days from the date of request;
(3) For obstetric and gynecological services, appointment wait times
must be no longer than fifteen (15) business days from the date of request; and
(4) For other services or specialties the bureau may identify, appointment
wait times must be no longer than the timeframes specified by the bureau in an
evidence-based manner.
(f)
(1) No less than annually, TennCare shall conduct a secret shopper
survey to determine the accuracy of the information specified in subdivision (f)(2)
for each MCO's most current electronic healthcare provider directories for the
following healthcare provider types, if included in the MCO's provider directory:
(A) Primary care providers;
(B) Obstetric and gynecological providers;
(C) Outpatient mental health and substance use disorder
providers; and
- 8 - 001446
(D) Providers of the services identified by the bureau under
subdivision (e)(4).
(2) At a minimum, a secret shopper survey must assess the accuracy of
the information in each MCO's most current electronic provider directories that
pertains to:
(A) The provider's active network status with the MCO;
(B) Provider street address;
(C) Provider telephone number; and
(D) Whether the provider is accepting new enrollees.
(g) When an entity conducting a secret shopper survey on behalf of the bureau
identifies an error in an MCO's directory data, the entity shall send information sufficient
for the MCO to correct the error to the bureau within three (3) business days after the
date the error is identified.
(h) The bureau shall send information received pursuant to subsection (g) to the
applicable MCO within three (3) business days after the date the bureau receives the
information from the entity that conducted the secret shopper survey.
(i)
(1) The bureau shall develop and enforce network adequacy standards
consistent with this section.
(2) The network standards established by the bureau in accordance with
this section must include all geographic areas covered by an MCO. The bureau
may establish varying standards for the same healthcare provider type based on
geographic area.
(3) The bureau shall not create exceptions to the network adequacy
standards developed under this subsection (i).
- 9 - 001446
(4) At a minimum, the bureau must develop a quantitative network
adequacy standard for MCOs, other than appointment wait time availability
standards, for the following provider types, if covered under an MCO's contract:
(A) Adult and pediatric primary care;
(B) Obstetrics and gynecology;
(C) Adult and pediatric mental health and substance use
disorders; and
(D) Adult and pediatric specialists, as designated by the bureau.
(j) The bureau shall publish the standards developed in accordance with this
section on its website in a manner that is easily accessible to the general public.
(k) If the bureau identifies a deficiency in an MCO's network adequacy under the
standards established by this section, then the bureau shall:
(1) Develop a remediation plan to address the deficiency which identifies
specific steps for the MCO to complete, contains timelines for implementation
and completion by the MCO, and includes a variety of approaches, including but
not limited to, increasing payment rates to providers; and
(2) Submit the remediation plan to the general assembly for approval no
later than one hundred eighty (180) calendar days after the date TennCare
becomes aware of the deficiency.
(l) No later than July 1, 2026, the department of finance and administration shall
promulgate rules to effectuate this section. The rules must include civil penalties for
violations of this section. The rules must be promulgated in accordance with the Uniform
Administrative Procedures Act, compiled in title 4, chapter 5.
SECTION 4. This act takes effect July 1, 2025, the public welfare requiring it.