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
Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
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
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
United States: includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
(1) Offers health insurance coverage or benefits under a contract that restricts reimbursement for covered services to a defined network of providers; and(2) Is regulated under this title or is an entity that accepts the financial risks associated with the provision of health care services by persons who do not own or control, or who are not employed by, the entity.(b)(1) Every managed health insurance issuer shall offer, or contract with another carrier to offer, an additional benefit at the option of the employee, or other principal enrollee, as follows:
(A) A point of service option that provides benefits for covered services through health professionals and providers who are not members of the network; or(B) A preferred provider organization plan.(2) The managed health insurance issuer shall fully disclose to the enrollee, in clear, understandable language, the terms and conditions of each option, the copayments or other cost-sharing features of each option and the costs associated with each option provided by the issuer. The commissioner shall promulgate rules regarding presentation of these terms and conditions, including a suggested standard format, to facilitate the comparison by the enrollee of the terms and conditions of each option. The obligation of a managed health insurance issuer to make the offer described in this section may be satisfied by the managed health insurance issuer providing to the employer or other plan sponsor presentation materials for dissemination to employees or principal enrollees.(c) The amount of any additional premium required for the options described in subsection (b) may be paid by the purchaser of the health plan or may be paid by the enrollee of the group. The additional premium, taking into account any copayments or other cost-sharing features, shall not exceed an amount that is fair and reasonable in relation to the benefits provided, as determined by the commissioner.(d)(1) Under the option described in subsection (b), the rate of reimbursement for health providers out of the network shall be the same as the rate of reimbursement for noncapitated providers in the network; provided, that copayment, co-insurance and other cost-sharing features may be different for out of network providers.(2) A managed health insurance issuer shall not be required to reimburse an out of network provider for nonemergency services unless the provider:
(A) Has disclosed to the patient a reasonable range of the total charges for the services being provided; and(B) Has advised the patient that the provider may bill the patient for the balance of any charges that are not otherwise reimbursed by the managed health insurance issuer. If, after request by the patient, the provider fails to disclose a reasonable range of the total of charges for any nonemergency services provided, the patient shall not be liable for the charges.(e) The option described in subsection (b) shall be a part of every contract issued by a managed health insurance issuer; provided, that an employer who employs not more than one hundred (100) full-time employees may reject the point of service option in writing.(f) The requirements of this section shall be satisfied if the employer or other person sponsoring the health insurance or health benefits plan includes for all principal enrollees a preferred provider organization plan, a plan that offers unrestricted access to providers, or a point of service benefit as specified in this section.(g) Nothing contained in this section shall be construed or interpreted as applying to the TennCare programs administered pursuant to the waivers approved by the United Statesdepartment of health and human services, to entities that qualify to participate in the Medicare+Choice program, or to individual health insurance contracts.(h) Notwithstanding any other law to the contrary, an HMO may underwrite directly the point of service benefit required by this section.
