TennCare

Plain English Breakdown

Checked against official source text during the last sync.

Emma's Bill for TennCare

This bill changes how TennCare decides what medical care to pay for by considering a patient's overall health condition instead of just the least expensive option.

What This Bill Does

• Changes TennCare rules so that when deciding if something is medically necessary, they must look at the whole person’s health and needs, not just the cheapest treatment.
• Requires TennCare to do a full medical review of each patient's condition before making decisions about care.
• Includes factors like how well someone can move or think, whether they need constant nursing help, and if they use life-support machines in their daily routine.

Who It Names or Affects

• People who are part of the TennCare program in Tennessee.
• TennCare officials who make decisions about medical care for patients.

Terms To Know

TennCare

A health insurance program run by the state of Tennessee that helps people get healthcare when they can't afford it on their own.

Medical necessity

The idea that a medical treatment or service is needed to treat an illness, injury, condition, or disease and should be covered by insurance.

Limits and Unknowns

• It's not clear how much this will cost the state and federal governments.
• This bill only affects people in Tennessee who use TennCare.

Official Summary Text

Present law provides that enrollees under
the TennCare program are eligible to receive, and TennCare must provide payment for, only those medical items and services that are within the scope of defined benefits for which the enrollee is eligible under the TennCare program and determined by the Te
n
nCare program to be medically necessary.

In order to be determined to be medically necessary, present law requires a medical item or service to be recommended by a physician who is treating the enrollee or other licensed healthcare provider practicing wi
thin the scope of the physician's license who is treating the enrollee and to satisfy certain criteria, one of which is that it must be the least costly alternative course of diagnosis or treatment that is adequate for the medical condition of the enrolle
e
. This bill provides an exception to this criterion.

W
hen making a determination of medical necessity,
this bill requires
the bureau of TennCare
to
take into consideration the patient's overall condition and use such overall condition as a factor to det
ermine the level of funding and what medical items and services the patient receives, even if such determination does not result in the least costly course of diagnosis or treatment. Consideration of a patient's overall condition requires a comprehensive

medical review of the patient and includes, but is not limited to, consideration of the patient's (i) mobility or ability to move or turn, (ii) cognitive awareness and ability to communicate, (iii) need for constant nursing supervision, and (iv) need for
a
ventilator or other life-sustaining equipment, regardless of the number of hours per day the patient uses the ventilator or other life-sustaining equipment.

Current Bill Text

SENATE BILL 650
By Crowe

HOUSE BILL 364
By Alexander

HB0364
001091
- 1 -

AN ACT to amend Tennessee Code Annotated, Title 4 and
Title 71, relative to TennCare.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
SECTION 1. This act is known and may be cited as "Emma's Bill."
SECTION 2. Tennessee Code Annotated, Section 71-5-144(b)(3), is amended by
deleting the language "It must be the least costly alternative" and substituting "Except as
provided in subsection (g), it must be the least costly alternative".
SECTION 3. Tennessee Code Annotated, Section 71-5-144, is amended by adding the
following as a new subsection:
(g) Notwithstanding this section to the contrary, when making a determination of
medical necessity, the bureau shall take into consideration the patient's overall condition
and use such overall condition as a factor to determine the level of funding and what
medical items and services the patient receives, even if such determination does not
result in the least costly course of diagnosis or treatment. Consideration of a patient's
overall condition requires a comprehensive medical review of the patient and includes,
but is not limited to, consideration of:
(1) The patient's mobility or ability to move or turn;
(2) The patient's cognitive awareness and ability to communicate;
(3) The patient's need for constant nursing supervision; and
(4) The patient's need for a ventilator or other life-sustaining equipment,
regardless of the number of hours per day the patient uses the ventilator or other
life-sustaining equipment.

- 2 - 001091

SECTION 4. This act takes effect July 1, 2025, the public welfare requiring it.