(a)Limitation on application of provisions relating to group health plans.

lawyer at desk

Ask an insurance law question, get an answer ASAP!
Click here to chat with a lawyer about your rights.

Terms Used In Tennessee Code 56-7-2807

  • Church plan: has the meaning given the term under §. See Tennessee Code 56-7-2802
  • Contract: A legal written agreement that becomes binding when signed.
  • Creditable coverage: means , with respect to an individual, coverage of the individual under any of the following:
    (i) A group health plan. See Tennessee Code 56-7-2802
  • Employee: has the meaning given the term under §. See Tennessee Code 56-7-2802
  • Excepted benefits: means benefits under one (1) or more, or any combination, of the following:
    (A) Benefits not subject to requirements:
    (i) Coverage only for accident or disability income insurance, or any combination of accident and disability income insurance. See Tennessee Code 56-7-2802
  • Governmental plan: has the meaning given the term under ERISA, §. See Tennessee Code 56-7-2802
  • Group health insurance coverage: means , in connection with a group health plan, health insurance coverage offered in connection with the plan. See Tennessee Code 56-7-2802
  • Group health plan: means an employee welfare benefit plan, as defined in ERISA, §. See Tennessee Code 56-7-2802
  • Health insurance coverage: means benefits consisting of medical care, provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care, under any policy, certificate, or agreement offered by a health insurance issuer. See Tennessee Code 56-7-2802
  • Medical care: means amounts paid for:
    (A) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body. See Tennessee Code 56-7-2802
  • Nonfederal governmental plan: means a governmental plan that is not a federal governmental plan. See Tennessee Code 56-7-2802
  • Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
  • Plan sponsor: has the meaning given the term under §. See Tennessee Code 56-7-2802
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(1) The requirements of this part shall apply with respect to group health plans only:

(A) Subject to subdivision (a)(2), in the case of a plan that is a nonfederal governmental plan; and
(B) With respect to health insurance coverage offered in connection with a group health plan, including a plan that is a church plan or a governmental plan.
(2)Treatment of nonfederal governmental plans.

(A) If the plan sponsor of a nonfederal governmental plan that is a group health plan to which this part otherwise applies makes an election under this subdivision (a)(2)(A) pursuant to regulations to be promulgated by the secretary of health and human services, then the requirements of this part insofar as it applies directly to group health plans, and not merely to group health insurance coverage, shall not apply to the governmental plans for the period except as provided in this subdivision (a)(2)(A).
(B) An election under subdivision (a)(2)(A) shall apply:

(i) For a single specified plan year; or
(ii) In the case of a plan provided pursuant to a collective bargaining agreement, for the term of the agreement. An election under subdivision (a)(2)(B)(i) may be extended through subsequent elections under this subdivision (a)(2)(B)(ii).
(C) Under such an election, the plan shall provide for:

(i) Notice to enrollees, on an annual basis and at the time of enrollment under the plan, of the fact and consequences of the election; and
(ii) Certification and disclosure of creditable coverage under the plan with respect to enrollees.
(b)Exception for Certain Benefits. The requirements of this part shall not apply to any group health plan or group health insurance coverage in relation to its provision of excepted benefits.
(c)Exception for Certain Benefits if Certain Conditions Met.

(1)Limited, Excepted Benefits. The requirements of this part shall not apply to any group health plan and group health insurance coverage offered in connection with a group health plan in relation to its provision of excepted benefits, if the benefits:

(A) Are provided under a separate policy, certificate or contract of insurance; or
(B) Are otherwise not an integral part of the plan.
(2)Noncoordinated, Excepted Benefits. The requirements of this part shall not apply to any group health plan and group health insurance coverage offered in connection with a group health plan in relation to its provision of excepted benefits if all of the following conditions are met:

(A) The benefits are provided under a separate policy, certificate, or contract of insurance;
(B) There is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor; and
(C) The benefits are paid with respect to an event without regard to whether benefits are provided with respect to the event under any group health plan maintained by the same plan sponsor.
(3)Supplemental Excepted Benefits. The requirements of this part shall not apply to any group health plan and group health insurance coverage in relation to its provision of excepted benefits, if the benefits are provided under a separate policy, certificate or contract of insurance.
(d)Treatment of Partnerships. For purposes of this part:

(1) Any plan, fund, or program that would not be, but for this subsection (d), an employee welfare benefit plan and that is established or maintained by a partnership, to the extent that the plan, fund, or program provides medical care, including items and services paid for as medical care, to present or former partners in the partnership or to their dependents, as defined under the terms of the plan, fund, or program, directly or through insurance, reimbursement, or otherwise, shall be treated, subject to subdivision (d)(2), as an employee welfare benefit plan that is a group health plan;
(2) In the case of a group health plan, “employer” also includes the partnership in relation to any partner; and
(3)Participants of Group Health Plans. In the case of a group health plan, “participant” also includes:

(A) In connection with a group health plan maintained by a partnership, an individual who is a partner in relation to the partnership; or
(B) In connection with a group health plan maintained by a self-employed individual, under which one (1) or more employees are participants, the self-employed individual, if such individual is, or may become, eligible to receive a benefit under the plan or the individual’s beneficiaries may be eligible to receive any such benefit.
  Previous section
Next section  
 Part 28 Contents