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SENATE BILL 1795
By Reeves
HOUSE BILL 1646
By Freeman
HB1646
009605
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AN ACT to amend Tennessee Code Annotated, Title 8;
Title 56 and Title 71, relative to insurance
coverage.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
SECTION 1. Tennessee Code Annotated, Title 56, Chapter 7, Part 10, is amended by
adding the following as a new section:
(a) As used in this section:
(1) "Acquired brain injury" or "ABI" means an injury to the brain which
occurs after birth and which may be caused by infectious diseases, metabolic
disorders, endocrine disorders, diminished oxygen, brain tumors, toxins, a
disease that affects the blood supply to the brain, stroke, or a traumatic brain
injury;
(2) "Adverse determination" means a determination by a clinical peer
reviewer that an admission, extension of stay, or another covered ABI service,
upon review based on the clinical information provided, is not medically
necessary;
(3) "Clinical peer reviewer" means a healthcare professional who
specializes and has experience in the delivery of treatments and services for
individuals with acquired brain injuries, and:
(A) If a requirement for a license, certificate, or registration exists,
the healthcare professional possesses the current and valid license,
certificate, or registration necessary to provide such treatments and
services; or
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(B) If no such requirement for a license, certificate, or registration
exists, the healthcare professional is credentialed by a national
accrediting body appropriate to the profession;
(4) "Cognitive communication therapy" means the treatment of
communication problems which have an underlying cause in one (1) or more
cognitive deficits rather than a primary language or speech deficit;
(5) "Cognitive rehabilitation therapy" or "CRT" means the process of
relearning cognitive skills essential for daily living through the coordination of
specialized, integrated, therapeutic treatments which are provided in dynamic
settings and designed for efficient and effective relearning following damage to
brain cells or brain chemistry due to brain injury;
(6) "Community reintegration services" means incremental, guided, real-
world therapeutic training to develop skills essential for an individual to
participate in daily living; reenter employment; go to school and engage in other
productive activities; safely live independently; and participate in the community
while avoiding rehospitalization and long-term support needs;
(7) "Functional rehabilitation therapy" means:
(A) A structured approach emphasizing learning by doing, and
focusing on relearning a specific task in a prescribed format, with
maximum opportunity for repeated correct practice and a focus on
relearning the skills essential for safe daily living in home and community
settings; and
(B) Includes compensatory strategies developed for the skills
which are persistently impaired and daily implementation training;
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(8) "Health benefit plan" means health insurance coverage as defined in
§ 56-7-109;
(9) "Medical necessity" or "medically necessary" means that a healthcare
service is consistent with generally accepted principles of professional medical
practice;
(10) "Neurobehavioral therapy" means medical and therapeutic
assessment and treatment focused on behavioral impairment associated with
brain disease or injury and the amelioration of such impairment through the
development of pro-social behavior;
(11) "Neurocognitive therapy" means treatment of a disorder in which the
primary clinical deficit is in cognitive function that has not been present since
birth and is a decline from a previously attained level of function;
(12) "Neurofeedback therapy" means a form of biofeedback whereby a
patient learns to control brain activity that is measured and recorded by an
electroencephalogram and is conducted through direct training of brain function
to enhance self-regulatory capacity or an individual's ability to exert control over
behavior, thoughts, and feelings;
(13) "Neuropsychological testing" means medical and therapeutic
assessment and treatment focused on amelioration of cognitive, emotional,
psychosocial, and behavioral deficits caused by brain injury;
(14) "Post-acute residential treatment" means integrated medical and
therapeutic services, treatment, education, and skills training provided in a home
and community setting that is designed to create the maximum opportunity for
correct practice of skill in the context of use to develop new neural pathways to
enable an individual to avoid rehospitalization and long-term care; and
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(15) "Vision therapy" means a sequence of doctor-supervised
procedures and activities individually prescribed and monitored to develop,
rehabilitate, and enhance visual skills and processing using lenses and other
optometric techniques.
(b)
(1) A health insurer or health maintenance organization that offers a
health benefit plan in this state shall provide coverage for medically necessary
treatment related to or resulting from an acquired brain injury.
(2) Medically necessary treatment under subdivision (b)(1) includes, but
is not limited to:
(A) Cognitive rehabilitation therapy;
(B) Cognitive communication therapy;
(C) Neurocognitive therapy and rehabilitation;
(D) Neurobehavioral therapy;
(E) Neurophysiological testing;
(F) Neuropsychological testing;
(G) Neurofeedback therapy;
(H) Vision therapy;
(I) Functional rehabilitation therapy;
(J) Community reintegration services;
(K) Post-acute residential treatment services;
(L) Inpatient services;
(M) Outpatient and day treatment services; and
(N) Home and community-based treatment.
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(3) Coverage required by this section must not include any lifetime
limitation or unreasonable annual limitation of the number of days or sessions of
treatment services. Any limitations on rehabilitation services in an inpatient
rehabilitation facility must be separate from, and must not be included in, any
limitations of post-acute rehabilitation. An insurer or health maintenance
organization shall separately state any limitations. Covered services required by
this section must not be subject to a greater deductible, coinsurance, copayment,
or out-of-pocket limitation than another covered service provided under a health
benefit plan by the health insurer or health maintenance organization.
(4) For services required to be covered by this section, a health insurer
or health maintenance organization shall ensure that only a clinical peer reviewer
conducts coverage preauthorization or utilization review.
(c) To be eligible for reimbursement for services required to be covered under
this section, an individual practitioner or treatment facility must be qualified to provide
acute care and post-acute care rehabilitation services to an individual with an acquired
brain injury by possessing the appropriate license, registration, certification, or
accreditation, training, and experience deemed customary and routine in the trade
practice, in addition to meeting the requirements for licensure, registration, certification,
or other permitting required by the law of this state.
(d) The commissioner of commerce and insurance shall promulgate rules to
create a process to permit an expedited appeal of any adverse determination by a health
insurer or health maintenance organization for services required to be covered under
this section.
SECTION 2. This act takes effect January 1, 2027, the public welfare requiring it, and
applies to contracts for insurance entered into, amended, or renewed on or after that date.