HB 651

PROHIBITIONS FOR HEALTH INSURANCE ENTITIES This bill prohibits a health insurance entity from engaging in any of the following:  Offer ing to a physician, advanced practice registered nurse, or a physician assistant (together, " healthcare provider "") a network provider agreement or otherwise condition ing the healthcare provider's network participation based on an all-products clause, which is a provision in a written or oral network provider agreement between a health insurance entity and a healthcare provider that requires the healthcare provider, as a condition of participation or continuation in a provider network or health benefit plan to (i) p articipate in another provider network that is utilized by the health insurance entity and affiliated with the health insurance entity or (ii) provide healthcare services under another plan or product offered by the health insurance entity .  Enter ing into a network provider agreement with a healthcare provider or otherwise condition ing the healthcare provider's network participation based on an all-products clause .  Amending or renewing an existing network provider agreement previously entered into with a healthcare provider so that the network provider agreement as amended or renewed adds or continues to include an all-products clause. Remedies If a network provider agreement contains a provision that violates such prohibitions, or if a health insurance entity otherwise conditions a healthcare provider's network participation ba sed on an all-products clause, such provision or condition is void and the commissioner of commerce and insurance must assess the entity a civil penalty of $10, 000 for each occurrence. Rulemaking On or before July 1, 2026, this bill requires the commissioner of commerce and insurance to promulgate rules to effectuate the provisions described above . PROHIBITIONS FOR MANAGED CARE ORGANIZATIONS (MCO) This bill prohibits an MCO from engaging in any of the following:  Offer ing to a healthcare provider a network provider agreement or otherwise condition ing the healthcare provider's network participation based on an all-products clause, which is a provision in a written or oral network provider agreement between a MCO or health insurance entity and a healthcare provider that requires the healthcare provider, as a condition of participation or continuation in a provider network or a health benefit plan to (i) participate in another provider network that is utilized by the MCO or health insurance entity and affiliated with the MCO or health insurance entity or (ii) provide healthcare services under another plan or product offered by the MCO or health insurance entity.  Entering into a network provider agreement with a healthcare provider or otherwise condition ing the healthcare provider's network participation based on an all-products clause .  Amending or renewing an existing network provider agreement previously entered into with a healthcare provider so that the network provider agreement as amended or renewed adds or continues to include an all-products clause. Remedies If a network provider agreement contains a provision that violates such prohibitions, or if an MCO otherwise conditions a healthcare provider's network participa tion based on an all-products clause, then this bill provides that such provision or condition is void and the commissioner of finance and administration must assess the MCO a civil penalty of $10, 000 for each occurrence. Rulemaking On or before July 1, 2026, this bill requires the commissioner of finance and administration to promulgate rules to effectuate the provisions described above . TENNCARE PROVIDER REMEDY PLAN This bill enacts the ""TennCare Provider Remedy Plan, "" which requ ires the bureau of TennCare (""bureau"") to establish and enforce appointment wait time standards and the accuracy of physician, advanced practice registered nurse, and physician assistant (together, ""healthcare provider"") directories by implementing a regul ar secret shopper survey to determine each MCO's compliance with the standards. An MCO is in compliance with such standards when secret shopper survey results reflect a rate of appointment wait time availability within the standard time frame of at least 90%. The bureau must determine if appointments offered via telehealth may be counted toward compliance with appointment wait time availability standards. Establishment of Wait Time Availability Standards This bill requires the bureau to establish wait time availability standards for routine appointments for the following services, if covered in an MCO's contract, and within the specified limits:  For outpatient mental health and substance use disorder services, adult and pediatric appointment wait times must be no longer than 1 0 business days from the date of request .  For primary care services, adult and pediatric appointment wait times must be no longer than 15 business days from the date of request .  For obstetric and gynecological services, appointment wait times must be no longer than 15 business days from the date of request .  For other services or specialties the bureau may identify, appointment wait times must be no longer than the timeframes specified by the bureau in an evidence-based manner. Secret Shopper Survey No less than annually, this bill requires TennCare to conduct a secret shopper survey to determine the accuracy of the infor mation for each MCO's most current electronic healthcare provider directories for the following healthcare provider types, if included in the MCO's provider directory : p rimary care providers; o bstetric and gynecological providers; o utpatient mental health and substance use disorder providers; and additional p roviders of services identified by the bureau. At a minimum, this bill requires a secret shopper survey to assess the accuracy of the information in each MCO's most current electronic provider directo ries that pertains to (i) t he provider's active network status with the MCO, (ii) the p rovider 's street address, ( iii ) the p rovider 's telephone number, and ( iv ) w hether the provider is accepting new enrollees. When an entity conducting a secret shopper s urvey on behalf of the bureau identifies an error in an MCO's directory data, this bill requires the entity to send information sufficient for the MCO to correct the error to the bureau within three business days after the date the error is identified. Th e bureau must send such information to the applicable MCO within three business days after the date the bureau receives the information from the entity that conducted the secret shopper survey. Establishment of Network Adequacy Standards This bill requ ires the bureau to develop and enforce network adequacy standards. Such standards must include all geographic areas covered by an MCO. The bureau may establish varying standards for the same healthcare provider type based on geographic area. However, t h e bureau must not create exceptions to the network adequacy standards . At a minimum, this bill requires the bureau to develop a quantitative network adequacy standard for MCOs, other than appointment wait time availability standards, for the following pr ovider types, if covered under an MCO's contract: a dult and pediatric primary care; o bstetrics and gynecology; a dult and pediatric mental health and substance use disorders; and additional a dult and pediatric specialists, as designated by the bureau. This bill requires the bureau to publish the standards on its website in a manner that is easily accessible to the general public. If the bureau identifies a deficiency in an MCO's network adequacy under the standards, then the bureau must (i) d evelop a r emediation plan to address the deficiency which identifies specific steps for the MCO to complete, contains timelines for implementation and completion by the MCO, and includes a variety of approaches, including increasing payment rates to providers; and ( ii) s ubmit the remediation plan to the general assembly for approval no later than 180 calendar days after the date TennCare becomes aware of the deficiency. Rulemaking No later than July 1, 2026, this bill requires the department of finance and admini stration to promulgate rules to effectuate the provisions described above . The rules must include civil penalties for violations of the provisions described above ."