3-15-510 - Independent study and reporting requirements. - Tennessee Statutes

3-15-510. Independent study and reporting requirements.

(a)  The legislative oversight committee on TennCare is directed to conduct a totally independent study of the TennCare pharmacy program, including, but not limited to, the following questions:

     (1)  What is the monitoring process to ensure that pharmacy programs are carefully implemented and reimbursement arranged so that patient care is not disrupted?

     (2)  Is the physician's judgment adequately recognized in ensuring that patients receive medically necessary treatments?

     (3)  Should new drugs and biologics be available and reimbursable initially in order to ascertain their ability to have an impact on the integrated costs of TennCare services?

     (4)  Are adequate disclosure measures in place to ensure patients are informed about the scope of the pharmaceutical benefit and of any restrictions on that benefit?

     (5)  By what method should the scientific and clinical integrity of health care decisions affecting TennCare enrollees be ensured?

     (6)  Through what process should TennCare enrollees have the opportunity to voice grievances and have access to an established process for appealing denials of care?

     (7)  What safeguards are in place to insure the preservation of a competitive marketplace that will result in the continuation of critical medical research and development?

(b)  The TennCare bureau, the TennCare pharmacy board and the department of finance and administration shall provide necessary assistance to the oversight committee on TennCare in conducting its study and the oversight committee is authorized to invite the participation of TennCare managed care organizations, TennCare providers, pharmacists, pharmaceutical manufacturers and voluntary health associations.

(c)  The oversight committee on TennCare shall report its findings and recommendations no later than January 10, 1997, to the chair of the senate general welfare, health and human resources committee, the chair of the house health and human resources committee and the special joint committee to study women's health.

(d)  (1)  The TennCare bureau shall file a report at least annually setting forth data and statistics relative to health care provided to women. The report shall include data regarding women's health and prenatal care as follows:

          (A)  Data provided to the health care financing administration;

          (B)  Data collected by the Tennessee department of health re: live births and deaths sorted by MCO;

          (C)  Data provided by MCOs to the TennCare bureau and the Tennessee department of health;

          (D)  Extrenal Quality Review Organization (EQRO) reports provided to the TennCare bureau.

     (2)  The report shall further include the number of women who received health care through the TennCare program, the type of care delivered, including the incidence of each type of care, the number of visits made to physician's offices as well as hospital admissions, evaluation of outcome data, and other information which would be useful to the general assembly in evaluating the manner in which health care is provided through the TennCare program to women.

(e)  The TennCare bureau and the Tennessee department of health shall develop data measures to assess the effectiveness of presumptive eligibility, the distribution of providers for each MCO for TennCare enrollees within each CHA region, and the incidences of early prenatal care for TennCare recipients. The MCOs shall be required to report regularly to the TennCare bureau using the data measures developed pursuant to this section.

(f)  The reports required by this section shall be provided to the TennCare oversight committee, the speakers of each house, the select committee on children and youth and the special joint committee to study women's health. The first annual report shall be due by December 1, 1997.

(g)  The TennCare bureau shall file a quarterly report for each of the first three (3) quarters of each year to include the following updates:

     (1)  Status of TennCare reforms and improvements, such as improving the technology and information system;

     (2)  Progress of annual re-verification of all TennCare recipients;

     (3)  Status of filling top-leadership positions in the bureau;

     (4)  Number of recipients on TennCare program and costs to the state;

     (5)  Viability of MCOs and providers in the TennCare program; and

     (6)  Success of fraud detection and prevention.

A final report shall be submitted during the fourth quarter of each year, which shall include information for the fourth quarter and summarize information relating to each of the above areas for the entire year. A copy of such report for each quarter shall be transmitted to the TennCare oversight committee and the fiscal review committee within fifteen (15) days of the end of each quarter.

[Acts 1996, ch. 1039, §§ 1-6; 1999, ch. 226, § 1; 2000, ch. 798, § 1.]