HB 2619

This bill establishes the Tennessee commission of insurance review ("commission"") for the purpose of reviewing complaints related to and enforcing the requirements of this bill. The commission consists of (i) the commissioner of health; (ii) one member appointed by the speaker of the house of representatives, with at least five years of experience as a healthcare professional; (iii) one member appointed by the speaker of the senate, with at least five years of experience as a healthcare professional; (i v) two members of the house of representatives; and (v) two members of the senate. After initial appointments, members' terms must be for four years. However, legislative members serve terms of only two years. Vacancies must be filled for the remainder o f the term of the member being replaced. This bill provides that members of the commission are entitled to receive reimbursement for the member's traveling and other necessary expenses incurred while engaged in the performance of any official duties. The commission is to be funded from the gen eral fund. However, the commission may also be financed through private funding and through public and private grants. AUTHORITY OF THE COMMISSION This bill provides that the commission has the power and authority to:  Adopt, modify, repeal, promulgate, and enforce rules for the conduct and affairs of the commission; enforcement of the commission's orders; and otherwise effectuate this bill.  Issue subpoenas requiring the attendance of witnesses and production of such evidence as requested, administer oaths, and take such testimony as deemed necessary to fulfill the commission's purpose. The chancery court of Wilson County has jurisdiction, upon application of the commission, in a case where a person refuses to comply with such a subpoena.  Offer advisory technical assistance to a health insurance entity or participating provider regarding appropriate claim or code review practices.  Order remedial actions regarding violations of this bill, including health insurance entity coding or claim practices.  Exercise all the powers and take all the actions necessary, proper, or convenient for the accomplishment of the purposes enumerated in this bill. This bill provides that a majority of the commission constitutes a quorum, and the concurrence of a majority of those present and voting on a matter is required for a determination of matters within the commission's jurisdiction. Further, this bill auth orizes the commission members to participate by electronic or other means of communication in connection with any meeting authorized by law. This bill requires the department of commerce and insurance to fully cooperate with the commission in the execution of this bill by timely providing any requested information and sharing relevant documents and data. COMPLAINTS This bill requires the commission to review and conduct informal hearings of complaints submitted to it regarding violations of this bill. Requests for such a hearing must be received within 30 days of the final adverse decision of the health insurance entity. However, a complainant to the commission must first make a complaint through the standard claim appeal process, or utilize any other available remedy offered by the health insurance entity before seeking an informal hearing before the commission. This bill authorizes the commission to consolidate complaints that raise substantially similar issues against the same health insurance entity to be heard together. In reviewing a complaint, this bill requires the commission to consider the reasonableness of the health insurance claim or code review practices and policies, use of such review practices in connection with the submitted complaint, and other evidence pr esented during the hearing. This bill authorizes the commission to receive affidavit evidence, transcripts, and other evidence of actions by the health insurance entity or participating provider, and to render its decision on the basis of that evidence. H owever, the commission may determine that an open hearing is appropriate. Appellate review of the commission's decisions is governed by the Uniform Administrative Procedures Act, with the Wilson County chancery court having jurisdiction over judicial rev iew of the commission's decisions. This bill authorizes the commission to order such remedial actions as necessary to address a participating provider's complaint and to request that the attorney general bring an action in a court of competent jurisdiction in the name of the state against an individual or entity for violations of this bill. In such a cause of action brought by the attorney general, the court may (i) issue orders and injunctions to restrain and prevent violations of this bill, (ii) impose compensatory and punitive damages, and (iii) order reasonable attorney fees and investigative costs be paid by the violator to the state. PROHIBITED ACTIONS This bill prohibits a health insurance entity from offering or maintaining a health insurance benefit plan in this state that, based on the participating provider's contracted fee for covered services, uses downcoding in a manner that prevents the provid er from collecting the fee for actual services performed either from the health benefit plan or the patient. As used in this bill, ""downcoding"" means the adjustment of a claim submitted to a health benefit plan to a less complex or lower cost procedure cod e . Changes to fee schedules and contracts This bill generally prohibits a health insurance entity from offering or maintaining a health benefit plan in this state that allows the health insurance entity to make material changes to the health benefit plan, including by changing a provider's fee s chedule, a provider manual, or a reimbursement rule or policy, without (i) providing at least 60 days' notice and an opportunity to negotiate the changes to the affected provider; and (ii) allowing an affected provider to terminate the provider's contract w ith the health insurance entity without penalty if an agreement is not reached. Further, a health insurance entity is generally prohibited from otherwise unilaterally making changes to the contract between the health insurance entity and a provider. How ever, these prohibitions do not apply to any of the following changes to a health benefit plan:  Any change in a provider's fee schedule due to a change effected by the federal or state government to its healthcare fee schedule, if the provider and health insurance carrier have previously agreed that the provider's fee schedule is based on a percentage or some other formula of a current government healthcare fee schedule.  Any change in a provider's reimbursement for drugs, immunizations, injectables, supplies, or devices if the provider and health insurance carrier or pharmacy benefits manager have previously agreed that any such reimbursement will be based on a percentage, or some other formula, of a price index not established by the health insurance carrier .  Any change in the provider's reimbursement for drugs, immunizations, injectables, supplies, or devices if the provider and the health insurance carrier or pharmacy benefits manager have previously agreed to any such reimbursement based on maximum allowable cost pricing.  Any change to Current Procedural Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes, International Statistical Classification of Disease and Related Health Problems (ICD) Codes, or other coding sets recognized or used by the centers for medicare and medicaid services (CMS) that a health insurance carrier utilized in creating a provider's fee schedule .  Any change to revenue codes as established by the National Uniform Billing Committee (NUBC) .  Any changes in a provider's fee schedule due to one or more of the following, if previously agreed to in a provider's agreement with a health insurance carrier: (i) payments made to the healthcare provider by the health insurance carrier or payments made to the health insurance carrier by the provider that are based on values or quality measures explicitly described in the written agreement between the provider and the health insurance carrier intended to improve care provided to the health insurance carrier's members ; (ii) e scalator or de-escalator clauses ; (iii) p rovisions that require adjustments to payment due to population health management performance or results ; or (iv) a ny arrangements, initiatives, or value-based payments relating to or resulting from the implementation or operation of the Tennessee Health Care Innovation Initiative or any successor state program applicable to provider agreements covered by this bill.  Changes in standard codes and guidelines developed by the American Medical Association or similar organization. Sending medical information outside of the United States This bill prohibits a health insurance entity from sending an enrollee's medical information or history to a person located outside of the United States for any purpose. Further, a health insurance entity is prohibited from entering into or renewing a c ontract that authorizes or requires the health insurance entity to send an enrollee's medical information or history to a person located outside of the United States for any purpose. Artificial intelligence This bill requires a health insurance entity to ensure that coding or claim reviews that are conducted using artificial intelligence are reviewed, approved, or sent for further review by a human healthcare provider reviewer prior to sending a determinati on to the participating provider who submitted the claim or the covered individual for whom the services underlying the claim were performed. Further, the healthcare provider who reviews and approves such a coding or claim review must have relevant exper ie nce in the healthcare field to which the code or claim being reviewed relates. As used in this bill, ""artificial intelligence"" means a machine-based system that (i) can, for a given set of human-defined objectives, make predictions, recommendations, or decisions; can influence real and virtual environments without significant human oversight; or can learn from experience in an automated manner and improve such performance when exposed to data sets; or (ii) is developed in any context, including software or physical hardware, and solves tasks requiring human-like perception, cognition, planning, learning, communication, or physical action . Removal of an enrollee This bill generally prohibits an entity from removing an enrollee from a group or group plan if the enrollee was covered in the prior year in the same group or group plan. However, an enrollee may be removed (i) for nonpayment of the required premiums; (ii) for fraud or misrepresentation of the policyholder, contract holder, or the enrollee or enrollee's representative; or (iii) when the number of enrollees covered under the plan is fewer than the number of insureds or percentage of enrollees required b y participation requirements under the plan, if applicable. Lasering This bill prohibits a health insurance entity from using lasering when underwriting a stop-loss plan for a health benefit plan offered in this state. As used in this bill, ""lasering"" means the practice of assigning a higher attachment point or deductible, or denying coverage, for a covered individual or group of covered individuals within the policy's coverage who have a known, high-cost medical condition or history of significant claims . Ownership of a healthcare provider On or after July 1, 2026, this bill prohibits a person from, directly or indirectly, owning, operating, or controlling the whole or any part of a healthcare provider in this state while the person also, directly or indirectly, owns, operates, or controls the whole or any part of a health insurance entity. This includes ownership of either a healthcare provider or health insurance entity through investment interests. If a person, directly or indirectly, owns, operates, or controls both a healthcare prov id er and health insurance entity prior to July 1, 2026, this bill prohibits such a person from requiring a covered individual to utilize a healthcare provider over which the person has such direct or indirect ownership or control. Further, if a person, directly or indirectly, owns, operates, or controls both a healthcare provider and health insurance entity prior to July 1, 2026, and is negotiating with the state to provide a plan, then such a person must disclose the ownership, operation, or control. License classifications This bill prohibits a health insurance entity from denying reimbursement or paying a different reimbursement rate to a provider with a different license classification if a covered service is within the scope of practice of a provider with a particular license classification and a health insurance entity provides reimbursement for that service when performed by a provider with a different license classification . This prohibition applies regardless of the billing modifier or coding designation used to ident ify the provider of the service. Further, a health insurance entity is prohibited from establishing or applying a different fee schedule, reimbursement methodology, conversion factor, unit valuation, payment adjustment, site-of-service differential, or c ode restriction, solely on the basis of the healthcare provider's licensure classification. This bill prohibits a health insurance entity from reducing or reimbursing rates for physicians or other providers for the purpose of avoiding compliance with the se prohibitions. ENTITY REVIEW This bill provides that the commission terminates on June 30, 2028, for purposes of the Tennessee Governmental Entity Review Law. RULEMAKING This bill authorizes the commission to promulgate rules to effectuate this bill. Further, all rules issued or promulgated by the department of commerce and insurance that relate to the functions, duties, and responsibilities of the commission are transfe rred to the commission to be administered and enforced by it. APPLICABILITY This bill applies to conduct occurring on or after July 1, 2026."