[Effective until 6/30/2025. See the Compiler’s Notes]

(a) The board shall provide for administration of the program by electing, in its plan of operation, to have the program administered in either or both of the following manners:

Terms Used In Tennessee Code 56-7-2909

  • Access Tennessee: means the nonprofit entity created pursuant to §. See Tennessee Code 56-7-2902
  • Board: means the Access Tennessee board of directors established pursuant to §. See Tennessee Code 56-7-2902
  • Commissioner: means the commissioner of finance and administration. See Tennessee Code 56-7-2902
  • Contract: A legal written agreement that becomes binding when signed.
  • Department: means the department of finance and administration. See Tennessee Code 56-7-2902
  • Health insurance coverage: means any hospital and medical expense incurred policy, nonprofit health care service plan contract, health maintenance organization subscriber contract, or any other health care plan or arrangement that pays for or furnishes medical or health care services, whether by insurance or otherwise. See Tennessee Code 56-7-2902
  • Insurer: means any entity that provides health insurance coverage in this state. See Tennessee Code 56-7-2902
  • Plan of operation: means the articles, bylaws, and operating rules and procedures adopted by the board pursuant to §. See Tennessee Code 56-7-2902
  • Program: means the Access Tennessee health insurance program, created in §. See Tennessee Code 56-7-2902
  • 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
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(1) By the commissioner; or
(2) By using a competitive procurement process to select one (1) or more insurers or third party administrators to administer the program.
(b) If the board elects to use a competitive procurement process to select an insurer or administrator, the board shall evaluate proposals submitted based on criteria established by the board, which shall include, but need not be limited to:

(1) The insurer’s or administrator’s demonstrated ability to handle health insurance coverage for individuals;
(2) The efficiency and timeliness of the insurer’s or administrator’s claim processing and payment procedures;
(3) The fees proposed to discharge the insurer’s or administrator’s responsibility;
(4) The insurer’s or administrator’s ability to apply effective cost containment programs and procedures and to administer the program in a cost-efficient manner;
(5) The insurer’s or administrator’s ability to implement effective disease and/or case management programs;
(6) The availability of a network of providers for the program; and
(7) The financial condition and stability of the insurer or administrator.
(c) A contracted insurer or administrator shall serve for a period specified in the contract between Access Tennessee and the selected insurer or administrator, subject to removal for cause and subject to any terms, conditions, and limitations of the contract.
(d) At least one (1) year prior to the expiration of each period of service by a selected insurer or administrator, the board shall invite eligible entities, including the current insurer or administrator, to submit proposals to serve for the succeeding period. Selection of the succeeding insurer or administrator shall be made at least six (6) months prior to the end of the current period.
(e) An insurer or administrator shall perform functions relating to the program that may be assigned to it, including:

(1) Determination of eligibility and collection of information regarding unfair referrals;
(2) Payment of claims based on rates established by the insurer or administrator;
(3) Establishment of a premium billing procedure for collection of premiums from persons covered under the program;
(4) Making available information relating to the proper manner of submitting a claim for payments and distribution forms upon which submission shall be made; and
(5) Performance of other functions necessary to assure timely payment of benefits to providers of services to persons covered under the program.
(f) An insurer or administrator shall submit regular reports to Access Tennessee, as required by the board regarding the operation of the program. The frequency, content, and form of the report shall be specified in the contract between Access Tennessee and the insurer or administrator.
(g) Following the close of each calendar year, the insurer or administrator shall determine net written and earned premiums, other state or federal funding received by the program, the expense of administration, and the paid and incurred losses for the year, taking into account investment income and other appropriate gains and losses. The administrator shall report this information to the board, the department and the comptroller of the treasury on a form prescribed by the commissioner.
(h) A contracted insurer or administrator shall be paid as provided in the contract between Access Tennessee and the contractor.
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