(a)

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Terms Used In Tennessee Code 56-32-107

  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Coinsurance: means an enrollee's share of covered medical expenses when an enrollee and the HMO share in a specific ratio of the covered medical expenses. 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.
  • Enrollee: means an individual who is enrolled in an HMO. See Tennessee Code 56-32-102
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Evidence of coverage: means any certificate, agreement or contract issued to an enrollee setting out the coverage to which the enrollee is entitled. 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
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • 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
  • premiums: as used in this chapter includes, but is not limited to, any and all payments made by the state to any entity providing health care services pursuant to any federal waiver received by the state that waives any or all of Title XIX of the federal Social Security Act, compiled in 42 U. See Tennessee Code 56-32-112
  • 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) Every enrollee residing in this state is entitled to evidence of coverage.
(2) No evidence of coverage, or amendment to the evidence of coverage, shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage, or amendment to the evidence of coverage, has been filed and approved by the commissioner.
(3)

(A) An evidence of coverage shall contain:

(i) No provisions or statements that are unjust, unfair, inequitable, misleading, deceptive, that encourage misrepresentation, or that are untrue, misleading or deceptive as defined in § 56-32-113(a);
(ii) A clear and concise statement if a contract, or a reasonably complete summary if a certificate, of:

(a) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled;
(b) Any limitation on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible, copayment or coinsurance feature;
(c) Where and in what manner information is available as to how services may be obtained; and
(d) The total amount of payment for health care services and the indemnity or service benefits, if any, that the enrollee is obligated to pay with respect to individual contracts; and
(iii) A clear and understandable description of the HMO’s method for resolving enrollee complaints.
(B) Any subsequent change may be evidenced in a separate document issued to the enrollee.
(4) A copy of the form of the evidence of coverage to be used in this state, and any amendment to the evidence of coverage, shall be subject to the filing and approval requirements of subdivision (a)(2), unless it is subject to the jurisdiction of the commissioner under the laws governing health insurance or hospital medical service corporations, in which event the filing and approval provisions of those laws shall apply. Specifically, with respect to premiums charged, §§ 56-26-102 and 56-26-202 and rules promulgated under that section shall apply. To the extent, however, that the provisions do not apply, the requirement in subsection (c) shall be applicable.
(b)

(1) No schedule of charges for enrollee coverage for health care services, or amendment to the schedule, may be used until a copy of the schedule, or amendment to the schedule, has been filed and approved by the commissioner.
(2) The charges may be established in accordance with actuarial principles for various categories of enrollees; provided, that charges applicable to an enrollee shall not be individually determined based on the status of the enrollee’s health. However, the charges shall not be excessive, inadequate or unfairly discriminatory. A certification by a qualified actuary or other qualified person acceptable to the commissioner of the appropriateness of the use of the charges, based on reasonable assumptions, shall accompany the filing together with adequate supporting information.
(c) The commissioner shall, within a reasonable period, approve any form if the requirements of subsection (a) are met. It is unlawful to issue the form or to use the schedule of charges until approved. The commissioner may require the submission of whatever relevant information the commissioner deems necessary in determining whether to approve or disapprove a filing made pursuant to this section. The commissioner, if disapproving the filing, shall notify the filer. In the notice of disapproval, the commissioner shall specify the reasons for the disapproval. The commissioner’s approval or disapproval of a filing shall otherwise occur in accordance with the standards established by §§ 56-26-102 and 56-26-202 and the related rules.
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