(a) The commissioner may suspend or revoke any certificate of authority issued to an HMO under this chapter if the commissioner finds that any of the following conditions exist:

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Terms Used In Tennessee Code 56-32-116

  • 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
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Department: means the department of commerce and insurance. See Tennessee Code 56-1-102
  • 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.
  • 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
  • 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
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(1) The HMO is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under § 56-32-103, unless amendments to the submissions have been filed with and approved by the commissioner;
(2) The HMO issues evidence of coverage or uses a schedule of charges for health care services that do not comply with the requirements of § 56-32-107;
(3) The HMO does not provide or arrange for basic health care services;
(4) The HMO is unable to fulfill its obligations to furnish health care services;
(5) The HMO is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(6) The HMO has failed to implement the complaint system required by § 56-32-110 [repealed] in a reasonable manner to resolve complaints;
(7) The HMO, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;
(8) The continued operation of the HMO would be hazardous to its enrollees;
(9) The HMO has otherwise failed substantially to comply with this chapter; or
(10) The HMO has filed with the department sworn financial statements that contain material omissions or errors.
(b) A certificate of authority shall be suspended or revoked only after compliance with the requirements of § 56-32-118.
(c) When the certificate of authority of an HMO is suspended, the HMO shall not, during the period of suspension, enroll any additional enrollees, except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.
(d) When the certificate of authority of an HMO is revoked, the HMO shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the HMO. It shall engage in no further advertising or solicitation whatsoever. The commissioner may, by written order, permit such further operation of the organization as the commissioner may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practicable opportunity to obtain continuing health care coverage.
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