As used in this chapter, the term:

(1) “Capitation” means the fixed amount paid by a prepaid limited health service organization to a health care provider under contract with the prepaid limited health service organization in exchange for the rendering of covered limited health services;

Terms Used In Tennessee Code 56-51-102

  • Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
  • Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-51-102
  • 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.
  • Department: means the department of commerce and insurance. See Tennessee Code 56-51-102
  • Enrollee: means an individual, including dependents, who is entitled to limited health services pursuant to a contract, or any other evidence of coverage, with a health maintenance organization, licensed pursuant to chapter 32 of this title, or a contract with a state or federal agency. See Tennessee Code 56-51-102
  • 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.
  • Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • Limited health service: means dental care services, vision care services, mental health services, substance abuse services, and pharmaceutical services. See Tennessee Code 56-51-102
  • 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.
  • Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds-type organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Tennessee Code 56-16-102
  • Prepaid limited health service organization: means any person, corporation, partnership, or any other entity that, in return for a prepayment from a health maintenance organization or a state or federal agency, undertakes to provide or arrange for, or provide access to, the provision of a limited health service to enrollees through an exclusive panel of providers. See Tennessee Code 56-51-102
  • Provider: means , but is not limited to, any physician, dentist, health facility, or other person or institution that is duly licensed in this state to deliver limited health services. See Tennessee Code 56-51-102
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(2) “Commissioner” means the commissioner of commerce and insurance;
(3) “Department” means the department of commerce and insurance;
(4) “Enrollee” means an individual, including dependents, who is entitled to limited health services pursuant to a contract, or any other evidence of coverage, with a health maintenance organization, licensed pursuant to chapter 32 of this title, or a contract with a state or federal agency;
(5) “Evidence of coverage” means the certificate, agreement, membership card, or contract issued pursuant to this chapter setting forth the coverage to which an enrollee is entitled through a health maintenance organization licensed pursuant to chapter 32 of this title or a state or federal agency;
(6) “Insolvent” means that all the statutory assets of the prepaid limited health service organization, if made immediately available, would not be sufficient to discharge all of its statutory liabilities or that the prepaid limited health service organization is unable to pay its debts as they become due in the usual course of business;
(7) “Limited health service” means dental care services, vision care services, mental health services, substance abuse services, and pharmaceutical services. “Limited health service” does not include inpatient, hospital surgical services, or emergency services except as the services are provided incident to the limited health services set forth in this subdivision (7). However, “limited health service” does not exclude inpatient mental health or inpatient substance abuse services;
(8) “Prepaid limited health service contract” means any contract entered into by a prepaid limited health service organization with a health maintenance organization or a state or federal agency to provide limited health services in exchange for a prepaid per capita or prepaid aggregate fixed sum;
(9) “Prepaid limited health service organization” means any person, corporation, partnership, or any other entity that, in return for a prepayment from a health maintenance organization or a state or federal agency, undertakes to provide or arrange for, or provide access to, the provision of a limited health service to enrollees through an exclusive panel of providers. A “prepaid limited health service organization” may not contract with individuals, but only through a health maintenance organization or a state or federal agency. This shall not limit the organization from contracting with providers to provide contracted services. “Prepaid limited health service organization” does not include:

(A) An entity otherwise authorized pursuant to the laws of this state to indemnify for any limited health service;
(B) A provider or entity when providing limited health services pursuant to a contract with a prepaid limited health service organization, a health maintenance organization, a health insurer, or a self-insurance plan; or
(C) Any person who, in exchange for fees, dues, charges or other consideration, provides access to a limited health service provider without assuming any responsibility for payment for the limited health service or any portion of the limited health service;
(10) “Provider” means, but is not limited to, any physician, dentist, health facility, or other person or institution that is duly licensed in this state to deliver limited health services;
(11) “Qualified independent actuary” means an actuary who is a member of the American Academy of Actuaries or the Society of Actuaries and who has experience in establishing rates for limited health services and who has no financial or employment interest in the prepaid limited health service organization;
(12) “Reporting period” means the annual accounting period or fiscal year, or any part of the accounting period or fiscal year, of the prepaid limited health service organization. The calendar year shall be the fiscal year for each prepaid limited health service organization;
(13) “Subscriber” means an individual on whose behalf a contract or arrangement has been entered into with a prepaid limited health service organization for health care services or other persons who also receive health care services as a result of the contract;
(14) “Surplus notes” means debt that has been subordinated to all claims of subscribers and general creditors of the organization and the debt instrument shall so state;
(15) “Statutory accounting principles” means generally accepted accounting principles, except as modified by this chapter; and
(16) “Working capital” means current assets minus current liabilities.
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