SB 650

Present law provides that enrollees under the TennCare program are eligible to receive, and TennCare must provide payment for, only those medical items and services that are within the scope of defined benefits for which the enrollee is eligible under the TennCare program and determined by the Te n nCare program to be medically necessary. In order to be determined to be medically necessary, present law requires a medical item or service to be recommended by a physician who is treating the enrollee or other licensed healthcare provider practicing wi thin the scope of the physician's license who is treating the enrollee and to satisfy certain criteria, one of which is that it must be the least costly alternative course of diagnosis or treatment that is adequate for the medical condition of the enrolle e . This bill provides an exception to this criterion. W hen making a determination of medical necessity, this bill requires the bureau of TennCare to take into consideration the patient's overall condition and use such overall condition as a factor to det ermine the level of funding and what medical items and services the patient receives, even if such determination does not result in the least costly course of diagnosis or treatment. Consideration of a patient's overall condition requires a comprehensive medical review of the patient and includes, but is not limited to, consideration of the patient's (i) mobility or ability to move or turn, (ii) cognitive awareness and ability to communicate, (iii) need for constant nursing supervision, and (iv) need for a ventilator or other life-sustaining equipment, regardless of the number of hours per day the patient uses the ventilator or other life-sustaining equipment.