(a) The powers of an HMO include, but are not limited to, the following:

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Terms Used In Tennessee Code 56-32-105

  • basic health care services: includes , but is not limited to, services made necessary as the result of Title XIX federal programs or waivers for which TennCare is primarily responsible for implementation or enforcement. See Tennessee Code 56-32-102
  • Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-32-102
  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Enrollee: means an individual who is enrolled in an HMO. See Tennessee Code 56-32-102
  • Health care services: means any services included in the furnishing to any individual of medical or dental care, or hospitalization, or incidental to the furnishing of the care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability. See Tennessee Code 56-32-102
  • Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
  • person: includes an individual, insurer, company, association, organization, Lloyds, society, reciprocal insurer or interinsurance exchange, partnership, syndicate, business trust, corporation, agent, general agent, broker, solicitor, service representative, adjuster, and every legal entity. See Tennessee Code 56-32-102
  • Property: includes both personal and real property. See Tennessee Code 1-3-105
  • Provider: means any physician, hospital or other person that is licensed or otherwise authorized in this state to furnish health care services. See Tennessee Code 56-32-102
  • State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
(1) The purchase, lease, construction, renovation, operation or maintenance of hospitals or medical facilities, or both, and their ancillary equipment, and property reasonably required for its principal office or for purposes necessary in the transaction of the business of the organization;
(2) The making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation or corporation under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing health care services to enrollees;
(3) The furnishing of health care services through providers that are under contract with or employed by the HMO;
(4) The contracting with any person for the performance on its behalf of certain functions, such as marketing, enrollment and administration;
(5) The contracting with an insurance company licensed in this state, or with a hospital or medical service corporation authorized to do business in this state, for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the HMO; and
(6) The offering of other health care services, in addition to basic health care services.
(b) An HMO shall file notice, with adequate supporting information, with the commissioner prior to the exercise of any power granted in subdivision (a)(1), (a)(2) or (a)(4), if the dollar amount resulting from such action would exceed twenty-five percent (25%) of surplus. The commissioner shall disapprove the exercise of power only if in the commissioner’s opinion it would substantially and adversely affect the financial soundness of the HMO and endanger its ability to meet its obligations. If the commissioner does not disapprove within thirty (30) days of the filing, it shall be deemed approved.
(c) All provider contracts must include a hold harmless clause that will relieve any enrollee of a licensed HMO from any liability for services rendered by the providers except for reasonable copayment and uncovered expenses.
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