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Current as of January 02, 2024 | Updated by Findlaw Staff
(a) As used in this section:
(1) “Biomarker” has the same meaning as defined in § 56-7-2369;
(2) “Biomarker testing” has the same meaning as defined in § 56-7-2369;
(3) “Health benefit plan” means health insurance coverage as defined in § 56-7-109;
(4) “Health insurer” means a health insurance entity as defined in § 56-7-109;
(5) “Nationally recognized clinical practice guideline” has the same meaning as defined in § 56-7-2369; and
(6) “TennCare health benefit plan” means a health benefit plan issued by a health insurer pursuant to an agreement with the bureau of TennCare to provide health insurance coverage for an enrollee in the medical assistance program.
(b) A TennCare health benefit plan that is issued, amended, or renewed on or after January 1, 2027, must provide coverage for biomarker testing when medically necessary pursuant to § 71-5-144.
(c) Biomarker testing must be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition when the test is supported by medical and scientific evidence, including, but not limited to:
(1) Labeled indications for a federal food and drug administration (FDA)-approved or FDA-cleared test;
(2) Indicated tests for an FDA-approved drug;
(3) Warnings and precautions on FDA-approved drug labels;
(4) Centers for medicare and medicaid services national coverage determinations or medicare administrative contractor local coverage determinations; or
(5) Nationally recognized clinical practice guidelines.
(d) A health insurer that issues a TennCare health benefit plan that covers biomarker testing shall provide biomarker testing within the same scope, and at the same duration and frequency, that other TennCare benefits are provided to enrollees.
(e) If utilization review, including, but not limited to, prior authorization, is required, then the health insurer, nonprofit health service plan, health maintenance organization, utilization review entity, or a third party acting on behalf of an organization or entity subject to this section must approve or deny a prior authorization request and notify the enrollee, the enrollee's healthcare provider, and each entity requesting authorization of the service in accordance with 42 CFR Part 438.
(f) An enrollee and participating provider must have access to a clear, readily accessible, and convenient process to request an exception to a coverage policy of, or an adverse utilization review by, a health insurer that issues a TennCare health benefit plan. The process must be made readily accessible on the public website of TennCare and each health insurer that issues TennCare health benefit plans.
(g) The director of TennCare is authorized to seek any federal waiver the director deems necessary to effectuate this section.
(h)(1) The commissioner of commerce and insurance shall compile a report on the usage of covered biomarker testing and cost savings generated pursuant to this section, based upon data reported to the department of commerce and insurance by health insurers.
(2) The commissioner may establish reporting standards by rule for the purpose of compiling data necessary to complete the report required by this subsection (h). The rules must be promulgated in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
(3) No later than February 1, 2029, the commissioner shall deliver a copy of the report to the chief clerk of the senate, the chief clerk of the house of representatives, and the legislative librarian. The report may be delivered by electronic means.
Cite this article: FindLaw.com - Tennessee Code Title 71. Welfare § 71-5-199c - last updated January 02, 2024 | https://codes.findlaw.com/tn/title-71-welfare/tn-code-sect-71-5-199c/
FindLaw Codes may not reflect the most recent version of the law in your jurisdiction. Please verify the status of the code you are researching with the state legislature before relying on it for your legal needs.
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