House panel advances bill to let TennCare consider patients’ overall condition in medical-necessity reviews

The Tennessee House Insurance Committee on Feb. 25 voted 18-0 to advance House Bill 0364, which would direct TennCare’s medical-review process to consider a patient’s overall condition when determining medical necessity and funding for services.

Representative Alexandra presented the bill and members heard emotional testimony from Mark and Jody Herod about their daughter, Emma, who suffered severe brain injury in 2016 and now requires 24-hour care, a tracheostomy, a feeding tube and nighttime ventilator support. Mark Herod said TennCare helped the family but that a later funding reduction removed nursing hours when Emma no longer met a single-hour threshold used in prior eligibility decisions.

"We would not be here today without it," Mark Herod said of TennCare support. He told the committee that a 2023 court decision had left the family without relief, saying in the hearing that the judge ruled current law required a patient to be on a ventilator for 12 hours a night to preserve prior funding levels. The Herods and Representative Alexandra said the bill would let TennCare consider other clinical indicators, not only a single-hours-per-night ventilator threshold.

Under the bill’s language presented to the committee, the bureau making medical-necessity determinations would take into account a patient’s mobility and ability to turn, cognitive awareness and communication, need for constant nursing supervision, and need for ventilator or other life-sustaining equipment "regardless of the number of hours per day the patient uses" such equipment.

Representative Alexandra brought the family to describe the practical impact. Mark Herod told the committee that when TennCare reduced funding after Emma no longer used a ventilator for 12 hours nightly, "that funding helped provide nursing care for Emma. By reducing the funding, we lost some of her nursing care." He described medical letters stating loss of nursing care could be detrimental.

Committee members asked no substantive questions before the roll call. The clerk reported 18 ayes and 0 nays; the bill was forwarded to the Senate Finance Ways and Means Subcommittee.

The bill would not itself change TennCare’s budget; it changes the criteria reviewers use when assessing medical necessity. Representative Alexandra said her intent was to require a comprehensive medical review so decisions reflect the patient's total needs rather than a single utilization metric.

The committee did not specify implementation dates or budgetary effects; TennCare would carry out any changes to its review procedures if the bill becomes law.

Votes at a glance: House Bill 0364 — motion carried 18-0; forwarded to the Senate Finance Ways and Means Subcommittee.

The committee returned to other items on the agenda after the vote.