Tennessee 2025-2026 Regular Session

Tennessee Senate Bill SB1372 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2	HOUSE BILL 651
3	3	By Williams
4	4
5	5	SENATE BILL 1372
6	6	By Watson
7	7
8	8
9	9	SB1372
10	10	001446
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13	13	AN ACT to amend Tennessee Code Annotated, Title 56
14	14	and Title 71, relative to health care.
15	15
16	16	WHEREAS, the General Assembly finds that since 2012 TennCare payments to
17	17	healthcare providers generally reimburse twenty-eight percent through thirty-four percent less
18	18	than Medicare; and
19	19	WHEREAS, the General Assembly requires TennCare to incentivize better access to
20	20	quality health care in rural and underserved communities; and
21	21	WHEREAS, recent federal regulations allow states to increase Medicaid payments for
22	22	many services to up to the average commercial rate to enable Medicaid plans to compete with
23	23	commercial plans when building provider networks; and
24	24	WHEREAS, it is prudent that, within the next twelve months, the Bureau of TennCare
25	25	develop a plan that identifies a variety of approaches, including increasing payment rates for
26	26	healthcare providers to parity with average commercial contracting rates, improving outreach
27	27	and problem resolution to providers, reducing barriers to provider credentialing and contracting,
28	28	providing for improved or expanded use of telehealth, and improving the timeliness and
29	29	accuracy of processes such as claim payment and prior authorization, and submit the plan to
30	30	the General Assembly for consideration during the following legislative session; now, therefore,
31	31	BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
32	32	SECTION 1. Tennessee Code Annotated, Title 56, Chapter 7, Part 1, is amended by
33	33	adding the following as a new section:
34	34	(a) As used in this section:
35	35
36	36
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39	39	(1) "All-products clause" means a provision in a written or oral network
40	40	provider agreement between a health insurance entity and a healthcare provider
41	41	that requires the healthcare provider, as a condition of participation or
42	42	continuation in a provider network or health benefit plan to:
43	43	(A) Participate in another provider network that is utilized by the
44	44	health insurance entity and affiliated with the health insurance entity; or
45	45	(B) Provide healthcare services under another plan or product
46	46	offered by the health insurance entity;
47	47	(2) "Commissioner" means the commissioner of commerce and
48	48	insurance;
49	49	(3) "Health insurance entity" has the same meaning as defined in § 56-7-
50	50	109; and
51	51	(4) "Healthcare provider" means:
52	52	(A) A physician acting within the scope of a valid license issued
53	53	pursuant to title 63, chapters 6 or 9;
54	54	(B) A nurse acting within the scope of a valid license issued
55	55	pursuant to title 63, chapter 7 and who has a certificate to practice as an
56	56	advanced practice registered nurse issued by the board of nursing under
57	57	§ 63-7-126; or
58	58	(C) A physician assistant acting within the scope of a valid license
59	59	issued pursuant to title 63, chapter 19.
60	60	(b) A health insurance entity shall not:
61	61	(1) Offer to a healthcare provider a network provider agreement or
62	62	otherwise condition the healthcare provider's network participation based on an
63	63	all-products clause;
64	64
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68	68	(2) Enter into a network provider agreement with a healthcare provider or
69	69	otherwise condition the healthcare provider's network participation based on an
70	70	all-products clause; or
71	71	(3) Amend or renew an existing network provider agreement previously
72	72	entered into with a healthcare provider so that the network provider agreement
73	73	as amended or renewed adds or continues to include an all-products clause.
74	74	(c) If a network provider agreement contains a provision that violates this
75	75	section, or if a health insurance entity otherwise conditions a healthcare provider's
76	76	network participation based on an all-products clause, such provision or condition is void
77	77	and the commissioner shall assess the health insurance entity a civil penalty of ten
78	78	thousand dollars ($10,000) for each occurrence.
79	79	(d) On or before July 1, 2026, the commissioner shall promulgate rules to
80	80	effectuate this section. The rules must be promulgated pursuant to the Uniform
81	81	Administrative Procedures Act, compiled in title 4, chapter 5.
82	82	SECTION 2. Tennessee Code Annotated, Title 71, Chapter 5, Part 23, is amended by
83	83	adding the following as a new section:
84	84	(a) As used in this section:
85	85	(1) "All-products clause" means a provision in a written or oral network
86	86	provider agreement between a MCO or health insurance entity and a healthcare
87	87	provider that requires the healthcare provider, as a condition of participation or
88	88	continuation in a provider network or a health benefit plan to:
89	89	(A) Participate in another provider network that is utilized by the
90	90	MCO or health insurance entity and affiliated with the MCO or health
91	91	insurance entity; or
92	92
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96	96	(B) Provide healthcare services under another plan or product
97	97	offered by the MCO or health insurance entity.
98	98	(2) "Bureau" means the bureau of TennCare;
99	99	(3) "Commissioner" means the commissioner of finance and
100	100	administration;
101	101	(4) "Health insurance entity" has the same meaning as defined in § 56-7-
102	102	109;
103	103	(5) "Healthcare provider" means:
104	104	(A) A physician acting within the scope of a valid license issued
105	105	pursuant to title 63, chapters 6 or 9;
106	106	(B) A nurse acting within the scope of a valid license issued
107	107	pursuant to title 63, chapter 7 and who has a certificate to practice as an
108	108	advanced practice registered nurse issued by the board of nursing under
109	109	§ 63-7-126; or
110	110	(C) A physician assistant acting within the scope of a valid license
111	111	issued pursuant to title 63, chapter 19; and
112	112	(6) "Managed care organization" or "MCO" means an appropriately
113	113	licensed health insurance entity contracted with the bureau to manage the
114	114	delivery of, provide for access to, contain the cost of, and ensure the quality of
115	115	specified covered medical and behavioral benefits to TennCare enrollees through
116	116	a network of qualified providers.
117	117	(b) An MCO shall not:
118	118	(1) Offer to a healthcare provider a network provider agreement or
119	119	otherwise condition the healthcare provider's network participation based on an
120	120	all-products clause;
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125	125	(2) Enter into a network provider agreement with a healthcare provider or
126	126	otherwise condition the healthcare provider's network participation based on an
127	127	all-products clause; or
128	128	(3) Amend or renew an existing network provider agreement previously
129	129	entered into with a healthcare provider so that the network provider agreement
130	130	as amended or renewed adds or continues to include an all-products clause.
131	131	(c) If a network provider agreement contains a provision that violates this
132	132	section, or if an MCO otherwise conditions a healthcare provider's network participation
133	133	based on an all-products clause, such provision or condition is void and the
134	134	commissioner shall assess the MCO a civil penalty of ten thousand dollars ($10,000) for
135	135	each occurrence.
136	136	(d) On or before July 1, 2026, the commissioner shall promulgate rules to
137	137	effectuate this section. The rules must be promulgated pursuant to the Uniform
138	138	Administrative Procedures Act, compiled in title 4, chapter 5.
139	139	SECTION 3. Tennessee Code Annotated, Title 71, Chapter 5, Part 23, is amended by
140	140	adding the following as a new section:
141	141	(a) This section is known and may be cited as the "TennCare Provider Remedy
142	142	Plan."
143	143	(b) As used in this section:
144	144	(1) "Bureau" means bureau of TennCare;
145	145	(2) "Department" means the department of finance and administration;
146	146	(3) "Health insurance entity" has the same meaning as defined in § 56-7-
147	147	109;
148	148	(4) "Healthcare provider" or "provider" means:
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153	153	(A) A physician acting within the scope of a valid license issued
154	154	pursuant to title 63, chapters 6 or 9;
155	155	(B) A nurse acting within the scope of a valid license issued
156	156	pursuant to title 63, chapter 7 and who has a certificate to practice as an
157	157	advanced practice registered nurse issued by the board of nursing under
158	158	§ 63-7-126; or
159	159	(C) A physician assistant acting within the scope of a valid license
160	160	issued pursuant to title 63, chapter 19;
161	161	(5) "Managed care organization" or "MCO" means an appropriately
162	162	licensed health insurance entity contracted with the bureau to manage the
163	163	delivery, provide for access, contain the cost, and ensure the quality of specified
164	164	covered medical and behavioral benefits to TennCare enrollees through a
165	165	network of qualified providers;
166	166	(6) "Secret shopper survey" or "survey" means a research methodology
167	167	where callers who do not identify themselves as evaluators pose as enrollees
168	168	trying to schedule an appointment with a healthcare provider to evaluate
169	169	appointment wait time availability and the accuracy of healthcare provider
170	170	directories; and
171	171	(7) "TennCare" has the same meaning as defined in § 71-5-2503.
172	172	(c) The bureau shall establish and enforce appointment wait time standards and
173	173	the accuracy of healthcare provider directories by implementing a regular secret shopper
174	174	survey to determine each MCO's compliance with the standards in subsections (e) and
175	175	(f).
176	176	(d) An MCO is in compliance with the standards established in subsection (e)
177	177	when secret shopper survey results reflect a rate of appointment wait time availability
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182	182	within the standard time frame of at least ninety percent (90%). The bureau shall
183	183	determine if appointments offered via telehealth may be counted toward compliance with
184	184	appointment wait time availability standards.
185	185	(e) The bureau shall establish wait time availability standards for routine
186	186	appointments for the following services, if covered in an MCO's contract, and within the
187	187	specified limits:
188	188	(1) For outpatient mental health and substance use disorder services,
189	189	adult and pediatric appointment wait times must be no longer than ten (10)
190	190	business days from the date of request;
191	191	(2) For primary care services, adult and pediatric appointment wait times
192	192	must be no longer than fifteen (15) business days from the date of request;
193	193	(3) For obstetric and gynecological services, appointment wait times
194	194	must be no longer than fifteen (15) business days from the date of request; and
195	195	(4) For other services or specialties the bureau may identify, appointment
196	196	wait times must be no longer than the timeframes specified by the bureau in an
197	197	evidence-based manner.
198	198	(f)
199	199	(1) No less than annually, TennCare shall conduct a secret shopper
200	200	survey to determine the accuracy of the information specified in subdivision (f)(2)
201	201	for each MCO's most current electronic healthcare provider directories for the
202	202	following healthcare provider types, if included in the MCO's provider directory:
203	203	(A) Primary care providers;
204	204	(B) Obstetric and gynecological providers;
205	205	(C) Outpatient mental health and substance use disorder
206	206	providers; and
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211	211	(D) Providers of the services identified by the bureau under
212	212	subdivision (e)(4).
213	213	(2) At a minimum, a secret shopper survey must assess the accuracy of
214	214	the information in each MCO's most current electronic provider directories that
215	215	pertains to:
216	216	(A) The provider's active network status with the MCO;
217	217	(B) Provider street address;
218	218	(C) Provider telephone number; and
219	219	(D) Whether the provider is accepting new enrollees.
220	220	(g) When an entity conducting a secret shopper survey on behalf of the bureau
221	221	identifies an error in an MCO's directory data, the entity shall send information sufficient
222	222	for the MCO to correct the error to the bureau within three (3) business days after the
223	223	date the error is identified.
224	224	(h) The bureau shall send information received pursuant to subsection (g) to the
225	225	applicable MCO within three (3) business days after the date the bureau receives the
226	226	information from the entity that conducted the secret shopper survey.
227	227	(i)
228	228	(1) The bureau shall develop and enforce network adequacy standards
229	229	consistent with this section.
230	230	(2) The network standards established by the bureau in accordance with
231	231	this section must include all geographic areas covered by an MCO. The bureau
232	232	may establish varying standards for the same healthcare provider type based on
233	233	geographic area.
234	234	(3) The bureau shall not create exceptions to the network adequacy
235	235	standards developed under this subsection (i).
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240	240	(4) At a minimum, the bureau must develop a quantitative network
241	241	adequacy standard for MCOs, other than appointment wait time availability
242	242	standards, for the following provider types, if covered under an MCO's contract:
243	243	(A) Adult and pediatric primary care;
244	244	(B) Obstetrics and gynecology;
245	245	(C) Adult and pediatric mental health and substance use
246	246	disorders; and
247	247	(D) Adult and pediatric specialists, as designated by the bureau.
248	248	(j) The bureau shall publish the standards developed in accordance with this
249	249	section on its website in a manner that is easily accessible to the general public.
250	250	(k) If the bureau identifies a deficiency in an MCO's network adequacy under the
251	251	standards established by this section, then the bureau shall:
252	252	(1) Develop a remediation plan to address the deficiency which identifies
253	253	specific steps for the MCO to complete, contains timelines for implementation
254	254	and completion by the MCO, and includes a variety of approaches, including but
255	255	not limited to, increasing payment rates to providers; and
256	256	(2) Submit the remediation plan to the general assembly for approval no
257	257	later than one hundred eighty (180) calendar days after the date TennCare
258	258	becomes aware of the deficiency.
259	259	(l) No later than July 1, 2026, the department of finance and administration shall
260	260	promulgate rules to effectuate this section. The rules must include civil penalties for
261	261	violations of this section. The rules must be promulgated in accordance with the Uniform
262	262	Administrative Procedures Act, compiled in title 4, chapter 5.
263	263	SECTION 4. This act takes effect July 1, 2025, the public welfare requiring it.