Health insurers, whether commercial health plans or public programs like Medicaid and Medicare, only wish to pay for care that is necessary. Every day they make decisions on what is and is not “medically necessary.”
Gov. Phil Bredesen has proposed a new definition of medical necessity for TennCare, Tennessee’s long-troubled Medicaid program. To be covered by TennCare, a health care service must be (1) required to diagnose and treat an enrollee’s medical condition, (2) safe and effective, (3) the least costly alternative course of treatment adequate to address the enrollee’s medical condition, and (4) not experimental or investigational.
Beneficiary advocates, who have a long and effective history of challenging TennCare in federal court, are concerned that the new definition is vague and overly restrictive. The Governor has promised to further refine it in regulations to minimize unintended consequences.
All this reminded me of the definition of medical necessaity I wrote for the Wisconsin Medicaid program in the 1990’s. While no definition is perfect, you might find this one interesting: