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TennCare codifies medical-necessity approach and cost calculations for adult private duty nursing
Summary
TennCare proposed permanent rules to clarify definitions and freeze cost inputs used to determine medical necessity for adult private duty nursing (PDN), a move intended to provide predictability as nursing costs rise; legislators raised concerns about reduced hours for transitioning young adults and MCO responsiveness.
Amanda Petri, associate counsel for TennCare, presented permanent rule amendments to codify definitions and how TennCare applies the "least costly alternative" prong of medical necessity for adult private duty nursing. The package aims to provide consistency and transparency in how hours are determined and to "freeze or lock in the cost used to determine medical necessity," TennCare said.
Petri and medical staff explained the rule reflects long-standing practice and responds to rapidly rising private duty nursing costs. "This includes the long standing statutory criteria that it must be the least costly course of treatment that is adequate for the member's medical condition," Petri said. Agency witnesses described the transition process for beneficiaries turning 21: assessments begin in advance, MCOs perform in-home evaluations, and medical providers, MCOs and TennCare staff all contribute to adequacy determinations.
Legislators, including Representative Hardaway, relayed constituent cases where transitions resulted in dramatically fewer hours and even repeated hospital readmissions; TennCare staff said the agency will not force institutionalization and that wraparound long-term care programs can be used to supplement home nursing hours. Committee members sought clarity about appeal timelines and MCO response times; TennCare staff cited federal prior-authorization response requirements (14 days for standard requests, moving to 7 days by statute change, and expedited reviews within 3 days).
After extended questioning the committee moved the rule forward with a policy recommendation.
