(a) If a health insurance issuer offers health insurance coverage in the small or large group market in connection with a group health plan, the issuer must renew or continue in force the coverage at the option of the plan sponsor of the plan except as provided in this section.
Fraud: Intentional deception resulting in injury to another.
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
Health insurance issuer: means an entity subject to the insurance laws of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide health insurance coverage, including, but not limited to, an insurance company, a health maintenance organization and a nonprofit hospital and medical service corporation. See Tennessee Code 56-7-2802
Health status-related factor: means any of the following factors: (A) Health status. See Tennessee Code 56-7-2802
Large group market: means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents, through a group health plan maintained by a large employer. See Tennessee Code 56-7-2802
Network plan: means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the issuer. See Tennessee Code 56-7-2802
Small group market: means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents, through a group health plan maintained by a small employer. See Tennessee Code 56-7-2802
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
(b)General Exceptions. A health insurance issuer may nonrenew or discontinue health insurance coverage offered in connection with a group health plan in the small or large group market based only on one (1) or more of the following:
(1) The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the issuer has not received timely premium payments;(2) The plan sponsor has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage;(3) The plan sponsor has failed to comply with a material plan provision relating to employer contribution or group participation rules, as permitted by this part or other applicable insurance law;(4) The issuer is ceasing to offer coverage in the market in accordance with subsection (c) and other applicable insurance law;(5) In the case of a health insurance issuer that offers health insurance coverage in the market through a network plan, there is no longer any enrollee in connection with the plan who lives, resides, or works in the service area of the issuer, or in the area for which the issuer is authorized to do business, and in the case of the small group market, the issuer would deny enrollment with respect to the plan under § 56-7-2805(b)(1)(A); and(6) In the case of health insurance coverage that is made available in the small or large group market only through one (1) or more bona fide associations, the membership of an employer in the association, on the basis of which the coverage is provided, ceases, but only if the coverage is terminated under this subdivision (b)(6) uniformly without regard to any health status-related factor relating to any covered individual.(c)Requirements for Uniform Termination of Coverage.(1) In any case in which an issuer decides to discontinue offering a particular type of group health insurance coverage offered in the small or large group market, coverage of the type may be discontinued by the issuer in accordance with state law in the market only if:
(A) The issuer provides notice to each plan sponsor provided coverage of this type in the market, and participants and beneficiaries covered under the coverage, of the discontinuation at least ninety (90) days prior to the date of the discontinuation of the coverage;(B) The issuer offers to each plan sponsor provided coverage of this type in the market the option to purchase all, or, in the case of the large group market, any, other health insurance coverage currently being offered by the issuer to a group health plan in the market; and(C) In exercising the option to discontinue coverage of this type and in offering the option of coverage under subdivision (c)(2)(B), the issuer acts uniformly without regard to the claims experience of those sponsors or any health status-related factor relating to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for the coverage.(2)(A) In any case in which a health insurance issuer elects to discontinue offering all health insurance coverage in the small group market or the large group market, or both markets, in this state, health insurance coverage may be discontinued by the issuer only in accordance with applicable state law and if:
(i) The issuer provides notice to the commissioner and to each plan sponsor, and participants and beneficiaries covered under the coverage, of the discontinuation at least one hundred eighty (180) days prior to the date of the discontinuation of the coverage; and(ii) All health insurance issued or delivered for issuance in this state in the market or markets is discontinued and coverage under the health insurance coverage in the market or markets is not renewed.(B) In the case of a discontinuation under subdivision (c)(2)(A) in a market, the issuer may not provide for the issuance of any health insurance coverage in the market and this state during the five-year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.(d)Exception for Uniform Modification of Coverage. At the time of coverage renewal, a health insurance issuer may modify the health insurance coverage for a product offered to a group health plan:
(1) In the large group market; or(2) In the small group market if, for coverage that is available in the market other than only through one (1) or more bona fide associations, the modification is consistent with state law and effective on a uniform basis among group health plans with that product.(e)Application to Coverage Offered Only through Associations. In applying this section in the case of health insurance coverage that is made available by a health insurance issuer in the small or large group market to employers only through one (1) or more associations, a reference to “plan sponsor” is deemed, with respect to coverage provided to an employer member of the association, to include a reference to the employer.
