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Tennessee Code Title 71. Welfare § 71-5-2003

Current as of January 02, 2024 | Updated by Findlaw Staff

(a) There is imposed on each covered hospital licensed as of July 1, 2023, an annual coverage assessment for fiscal year (FY) 2023-2024 as set forth in this part.

(b) The annual coverage assessment imposed by this part is not effective and validly imposed until the bureau has provided the Tennessee Hospital Association with written notice that includes:

(1) A determination from CMS that the annual coverage assessment is a permissible source of revenue that does not adversely affect the amount of federal financial participation in the TennCare program;

(2)(A) Approval from CMS for the distribution of the full amount of directed payments to hospitals to offset unreimbursed TennCare costs as described in § 71-5-2005(d)(2) as long as an assessment installment is not collected prior to the distribution of the installment of the directed payments; or

(B) The rules promulgated by the bureau pursuant to § 71-5-2004(j)(2); and

(3) Confirmation that all contracts between hospitals and managed care organizations comply with the hospital payment rate variation corridors set forth in § 71-5-161.

(c) The general assembly intends that the proceeds of the annual coverage assessment are not to be used as a justification to reduce or eliminate state funding to the TennCare program. The annual coverage assessment is not effective and validly imposed if the coverage or the amount of revenue available for expenditure by the TennCare program in FY 2023-2024 is less than:

(1) The governor's FY 2023-2024 recommended budget level; plus

(2) Additional appropriations made by the general assembly to the TennCare program for FY 2023-2024, except to the extent new federal funding is available to replace funds that are appropriated as described in subdivision (c)(1) and that are above the amount that the state receives from CMS under the regular federal matching assistance percentage.

(d)(1)(A) The general assembly intends that the proceeds of the annual coverage assessment are not to be used as justification for a TennCare managed care organization to implement across-the-board rate reductions to negotiated rates with covered or excluded hospitals or physicians in existence on July 1, 2023. For those rates in effect on July 1, 2023, the bureau shall include provisions in the managed care organizations' contractor risk agreements that prohibit the managed care organizations from implementing across-the-board rate reductions to covered or excluded network hospitals or physicians by specific service, category, or type of provider. The requirements of the preceding sentence also apply to services or settings of care that are ancillary to the primary license of a covered or excluded hospital or physician, but do not apply to reductions in benefits or reimbursement for the ancillary services if the reductions:

(i) Are different from those items being funded in § 71-5-2005(d); and

(ii) Have been communicated in advance of implementation to the general assembly and the Tennessee Hospital Association.

(B) As used in this subsection (d):

(i) “Physician” includes a physician licensed under title 63, chapter 6 or chapter 9, and a group practice of physicians that holds a contract with a managed care organization;

(ii) “Services or settings of care that are ancillary” includes ambulatory surgical facilities, free standing emergency departments, outpatient treatment clinics or imaging centers, dialysis centers, home health and related services, home infusion therapy services, outpatient rehabilitation, or skilled nursing services; and

(iii) “Services or settings of care that are ancillary to the primary license of a covered or excluded hospital or physician” includes services where the physician or covered or excluded hospital, including a wholly owned subsidiary or controlled affiliate of a covered or excluded hospital or hospital system, holds more than a fifty percent (50%) controlling interest in the ancillary services or settings of care, but does not include other ancillary services or settings of care. For across-the-board rate reductions to ancillary services or settings of care, the bureau shall include appropriate requirements for notice to providers in the managed care organizations' contractor risk agreements.

(2) This subsection (d) does not preclude good faith negotiations between managed care organizations and covered or excluded hospitals, hospital systems, and between managed care organizations and physicians on an individualized, case-by-case basis. This subsection (d) does not serve as justification for managed care organizations in this state, covered or excluded hospitals, hospital systems, or physicians to unreasonably deny a party the ability to enter into individualized, case-by-case good faith negotiations. Good faith negotiation necessarily implies mutual cooperation between the negotiating parties and may include, but is not limited to, the right to terminate contractual agreements; the ability to modify negotiated rates, pricing, or units of service; the ability to alter payment methodologies; and the ability to enforce existing managed care techniques or to implement new managed care techniques.

(3) This subsection (d) does not preclude the full implementation of § 71-5-161.

(4) Notwithstanding this subsection (d), if CMS mandates a TennCare program change or a change is required by state or federal law that impacts rates, and that change is required to be implemented by the managed care organizations in accordance with their contracts, or if the annual coverage assessment becomes invalid, then this part does not prohibit the managed care organizations from implementing a rate change as may be mandated by the bureau or by state or federal law.

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Cite this article: FindLaw.com - Tennessee Code Title 71. Welfare § 71-5-2003 - last updated January 02, 2024 | https://codes.findlaw.com/tn/title-71-welfare/tn-code-sect-71-5-2003/

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