Part 1 General Provisions
Part 2 General Provisions–Life Insurance
Part 3 Life Insurance Policies
Part 4 Standard Nonforfeiture Law
Part 5 Contingent and Mortality Contracts
Part 7 Industrial Insurance
Part 8 Fire Insurance
Part 9 Credit Life and Health Insurance
Part 10 Health and Accident Insurance
Part 11 General Provisions–Auto Insurance
Part 12 Uninsured Motor Vehicle Coverage
Part 13 Cancellation of Auto Insurance
Part 14 Medicare Supplement Insurance
Part 16 Easy to Read Life and Health Insurance Policy Act
Part 17 Prepaid Dental Plans
Part 18 Cancellation of Commercial Risk Insurance Act
Part 19 Cancellation of Personal Risk Insurance
Part 20 Memphis Plan Act of 1991
Part 21 Pet Insurance
Part 22 Tennessee Small Employer Group Health Coverage Reform Act
Part 23 Mandated Insurer or Plan Coverage
Part 24 Mandated Scope of Practice
Part 25 Mandated Insurer or Plan Options
Part 26 Mandated Offerings of Coverage
Part 27 Genetic Information Nondiscrimination in Health Insurance Act
Part 28 Health Insurance Portability, Availability and Renewability Act
Part 29 Access Tennessee Act of 2006
Part 30 Cover Tennessee Act of 2006
Part 31 Pharmacy Benefits Managers
Part 32 Pharmacy Benefits
Part 33 Contracts with Health Care Providers

Terms Used In Tennessee Code > Title 56 > Chapter 7

  • Access Tennessee: means the nonprofit entity created pursuant to §. See
  • Actual reimbursement: means the total amount that a covered entity or pharmacy benefits manager determines that a pharmacy or other dispenser will receive consistent with the provider agreement, and is the sum of the amount the covered entity or pharmacy benefits manager will pay directly to the pharmacy or other dispenser plus any applicable patient out-of-pocket cost paid directly by the patient to the pharmacy or other dispenser, for dispensing of a particular prescription or providing a covered service. See
  • Actuarial certification: means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a small employer carrier is in compliance with §. See
  • Advisory committee: means the committee established pursuant to §. See
  • Agriculture: means :

    (i) The land, buildings and machinery used in the commercial production of farm products and nursery stock. See Tennessee Code 1-3-105

  • Attorney: means the person designated and authorized by subscribers as the attorney-in-fact having authority to obligate them on reciprocal insurance contracts. See
  • Base premium rate: means , for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under a rating system for that class of business, by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage. See
  • Basic health care plan: means a health care plan for small employers that is lower in cost than a standard health care plan and is required to be offered by all small employer carriers pursuant to §. See
  • Beneficiary: has the meaning given such term under §. See
  • Board: means the Access Tennessee board of directors established pursuant to §. See
  • Board: means the board of directors of the pool. See
  • Bona fide association: means , an association that:

    (A) Has been actively in existence for at least five (5) years. See

  • Carrier: means any person that provides one (1) or more health benefit plans in this state, including a licensed insurance company, a prepaid hospital or medical service plan, a health maintenance organization (HMO) and a multiple employer welfare arrangement (MEWA). See
  • Case characteristics: means demographic or other objective characteristics of a small employer, as determined by a small employer carrier, that are considered by the small employer carrier in the determination of premium rates for the small employer, but does not mean claim experience, health status and duration of coverage since issue. See
  • Church plan: has the meaning given the term under §. See
  • Class of business: means all or a distinct grouping of small employers as shown on the records of a small employer carrier. See
  • COBRA continuation coverage: refers to continuation of coverage offered pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985, compiled in 42 U. See
  • COBRA continuation provision: means any of the following:

    (A) Section 4980B of the Internal Revenue Code of 1986, codified in 26 U. See

  • Code: includes the Tennessee Code and all amendments and revisions to the code and all additions and supplements to the code. See Tennessee Code 1-3-105
  • Commercial risk insurance: means insurance within the scope of this part that is not "personal risk insurance" as defined in §. See
  • Commissioner: means the commissioner of commerce and insurance. See
  • Commissioner: means the commissioner of finance and administration. See
  • Commissioner: means the commissioner of finance and administration. See
  • Committee: means the small employer carrier committee, as created by §. See
  • Contractor: means a health insurance carrier or third party assets of the estate, pay debts, and distribute residue to those entitled to it. See
  • Contributing employer: means an employer that has, pursuant to §. See
  • cooperative: means a private purchasing cooperative composed of small employers formed under this part. See
  • Covered entity: means a health insurance issuer, managed health insurance issuer as defined in §. See
  • Covered entity: means a covered entity as defined in §. See
  • Covered person: means a person on whose behalf a health insurance entity offering health insurance coverage is obligated to pay benefits or provide services. See
  • Creditable coverage: means , with respect to an individual, coverage of the individual under any of the following:

    (i) A group health plan. See

  • Department: means the department of commerce and insurance. See
  • Department: means the department of finance and administration. See
  • Department: means the department of finance and administration. See
  • Dependent: means a dependent of an eligible individual, as defined by the department. See
  • Dependent: means the spouse or child of an eligible employee, subject to applicable terms of the health care plan covering the employee. See
  • Eligible employee: means an employee who works for a small employer on a full-time basis, with a normal work week of thirty (30) or more hours, including a sole proprietor, a partner or a partnership, or an independent contractor, if included as an employee under a health care plan of a small employer. See
  • Eligible individual: means an individual who meets the eligibility criteria established by the department pursuant to §. See
  • Employee: has the meaning given the term under §. See
  • Employer: has the meaning given the term under §. See
  • Enrollee: means an eligible individual or a dependent who is enrolled in a plan. See
  • Enrollment date: means , with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for the enrollment. See
  • Excepted benefits: means benefits under one (1) or more, or any combination, of the following:

    (A) Benefits not subject to requirements:

    (i) Coverage only for accident or disability income insurance, or any combination of accident and disability income insurance. See

  • Executor: includes an assets of the estate, pay debts, and distribute residue to those entitled to it. See Tennessee Code 1-3-105
  • Family member: means with respect to an individual, another individual related by blood to that individual. See
  • Federally defined eligible individual: means an individual:

    (A) For whom, as of the date on which the individual seeks coverage under this part, the aggregate of the periods of creditable coverage is eighteen (18) or more months. See

  • Foreign: when used without limitation, includes all companies formed by authority of any other state or government. See
  • Fund: means the Access Tennessee health insurance pool fund established by §. See
  • Genetic information: means information derived from genetic testing to determine the presence or absence of variations or mutations, including carrier status, in an individual's genetic material or genes that are scientifically or medically believed to cause a disease, disorder or syndrome, or are associated with a statistically increased risk of developing a disease, disorder or syndrome, that is asymptomatic at the time of testing. See
  • Genetic services: means health services to obtain, assess, and interpret genetic information for diagnostic and therapeutic purposes, and for genetic education and counseling. See
  • Governmental plan: has the meaning given the term under ERISA, §. See
  • Group health insurance coverage: means , in connection with a group health plan, health insurance coverage offered in connection with the plan. See
  • Group health plan: means an employee welfare benefit plan, as defined in ERISA, §. See
  • Health benefit plan: means :

    (i) Any accident and health insurance policy or certificate. See

  • Health benefits coverage: includes medical insurance in force currently or in force during the past six (6) months that would make a participating employer or enrollee ineligible pursuant to §. See
  • Health care provider: means any person or entity performing services regulated pursuant to title
  • Health insurance coverage: means a contractual arrangement for the provision of a payment for health care, including:

    (A) A group health plan. See

  • 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
  • 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
  • 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
  • Health status-related factor: means any of the following factors:

    (A) Health status. See

  • Hospital: means a licensed public or private institution as defined in §. See
  • Index rate: means , for each class of business as to a rating period for small employers with similar case characteristics, the arithmetic average of the applicable base premium rate and the corresponding highest premium rate. See
  • Individual health insurance coverage: means health insurance coverage offered to individuals in the individual market, but does not include short-term limited duration insurance. See
  • Individual market: means the market for health insurance coverage offered to individuals other than in connection with a group health plan. See
  • Insane: includes all persons of unsound mind. See Tennessee Code 1-3-105
  • Insurance arrangement: means , to the extent permitted by ERISA, any plan, program, contract or other arrangement under which one (1) or more employers, unions or other organizations provide to their employees or members, either directly or indirectly through a trust or third party administration, health care services or benefits other than through an insurer, and shall include any plan described in §. See
  • insurance company: includes all corporations, associations, partnerships, or individuals engaged as principals in the business of insurance. See
  • Insurance provider: means an insurer or other entity providing health insurance coverage. See
  • Insurer: means any entity that provides health insurance coverage in this state. See
  • insurer: means any life or health insurance company, fraternal benefit society, nonprofit health service corporation, nonprofit hospital service corporation, nonprofit medical service corporation, prepaid health plan, dental care plan, vision care plan, pharmaceutical plan, health maintenance organization, and all similar type organizations. See
  • Involuntary loss of coverage: means the loss of health benefits coverage arising from, but not limited to, the following circumstances:

    (i) A separation from employment, voluntary or involuntary. See

  • Large employer: means , in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least fifty-one (51) employees on business days during the preceding calendar year and who employs at least two (2) employees on the first day of the plan year. See
  • 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
  • Late enrollee: means an eligible employee or dependent who requests enrollment in a health benefit plan of a small employer following the initial enrollment period provided under the terms of the health benefit plan. See
  • Late enrollee: means , with respect to coverage under a group health plan, a participant or beneficiary who enrolls under the plan other than during:

    (A) The first period in which the individual is eligible to enroll under the plan. See

  • Medicaid: means the federal- and state-financed, state-run program of medical assistance established pursuant to Title XIX of the Social Security Act, compiled in 42 U. See
  • Medical care: means amounts paid for:

    (A) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body. See

  • Medicare: means coverage under Parts A and/or B of Title XVIII of the Social Security Act, compiled in 42 U. See
  • Minor: means any person who has not attained eighteen (18) years of age. See Tennessee Code 1-3-105
  • Month: means a calendar month. See Tennessee Code 1-3-105
  • 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
  • New business premium rate: means , for each class of business as to a rating period, the lowest premium rate charged, offered or that could have been charged by a small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage. See
  • Nonpayment of premium: means failure of the named insured to discharge when due any obligations in connection with the payment of premiums on a policy of automobile liability insurance or any installment of the premium, whether the premium is payable directly to the insurer or its agent or indirectly under any premium finance plan or extension of credit. See
  • Nonpayment of premium: means failure of the named insured to discharge when due any of its obligations in connection with the payment of premiums on a policy of commercial risk insurance or any installment of the premium, whether the premium is payable directly to the insurer or its agents or indirectly under any premium finance plan or extension of credit. See
  • Oath: includes affirmation. See Tennessee Code 1-3-105
  • Participant: has the meaning given the term under ERISA, §. See
  • Participating small employer: means an employer with fifty (50) or fewer employees, a significant proportion of whom are low income employees, that meets the eligibility criteria established pursuant to §. See
  • Person: includes a corporation, company, association, firm, partnership, society, and joint stock company, as well as an individual. See
  • 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
  • Personal property: includes money, goods, chattels, things in action, and evidences of debt. See Tennessee Code 1-3-105
  • Personal representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. See Tennessee Code 1-3-105
  • Pharmacy benefits manager: includes , but is not limited to, a health insurance issuer, managed health insurance issuer as defined in §. See
  • Pharmacy benefits manager: means a pharmacy benefits manager as defined in §. See
  • Plan: means the health benefits coverage offered by a contractor to eligible individuals. See
  • Plan of operation: means the articles, bylaws, and operating rules and procedures adopted by the board pursuant to §. See
  • Plan sponsor: has the meaning given the term under §. See
  • policy form: means :

    (A) Any policy, contract, plan or agreement of life or health insurance, including credit life insurance and credit health insurance, delivered or issued for delivery in this state by any company subject to this part. See

  • Pool: means the Tennessee small employer health reinsurance pool created by §. See
  • Pool: means the Access Tennessee health insurance pool, created in §. See
  • Preexisting condition exclusion: means , with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date. See
  • Preexisting conditions provision: means a policy provision that limits or excludes coverage for charges or expenses incurred during a specified period following the insured's effective date of coverage, for a condition that, during a specified period immediately preceding the effective date of coverage, had manifested itself in a manner that would cause an ordinarily prudent person to seek diagnosis, care or treatment, or for which medical advice, diagnosis, care or treatment was recommended or received as to that condition or as to pregnancy existing on the effective date of coverage. See
  • Premium: includes insurance premiums or other fees charged for a health benefit plan, including the costs of benefits paid or reimbursements made to or on behalf of persons covered by the plan. See
  • Private passenger automobile liability insurance policy: means a policy delivered or issued for delivery in this state, insuring a natural person as named insured, or one (1) or more related individuals resident of the same household, and under which the insured vehicles therein designated are of the following types only:

    (A) A motor vehicle of the private passenger or station wagon type that is not used as a public or livery conveyance for passengers, nor rented to others. See

  • Program: means the Cover Tennessee program established pursuant to this part. See
  • Property: includes both personal and real property. See Tennessee Code 1-3-105
  • provider: means any person or entity performing services regulated pursuant to title
  • Rating period: means the calendar period for which premium rates established by a small employer carrier are assumed to be in effect, as determined by the small employer carrier. See
  • Reasonably accurate: means information determined through application by the health insurance entity of contract rates, fee schedules and reimbursement rules and policies in effect as of the date inquiry is made by the provider. See
  • Record: means information that is inscribed on a tangible medium or that is stored in an electronic or other medium and is retrievable in a perceivable form. See Tennessee Code 1-3-105
  • Reinsuring carrier: means a small employer carrier electing to comply with the requirements set forth in §. See
  • Representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. See Tennessee Code 1-3-105
  • Resident: means an individual who is legally domiciled in Tennessee. See
  • Risk-assuming carrier: means a small employer carrier electing to comply with the requirements set forth in §. See
  • signed: includes a mark, the name being written near the mark and witnessed, or any other symbol or methodology executed or adopted by a party with intention to authenticate a writing or record, regardless of being witnessed. See Tennessee Code 1-3-105
  • Significant break in coverage: means a period of sixty-three (63) consecutive days during all of which the individual does not have any creditable coverage, except that neither a waiting period nor an affiliation period is taken into account in determining a significant break in coverage. See
  • Small employer: means , in connection with a group health plan with respect to a calendar year and a plan year, an employer who employs an average of at least two (2) but no more than fifty (50) employees on business days during the preceding calendar year and who employs at least two (2) employees on the first day of the plan year. See
  • small employer: includes any person that, during the preceding year, employed no less than two (2) and no more than fifty (50) eligible employees and otherwise qualifies as a small employer pursuant to this subdivision (23). See
  • Small employer carrier: means any carrier that offers health benefit plans covering eligible employees of one (1) or more small employers. See
  • 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
  • Standard health care plan: means a health care plan for small employers required to be offered by all small employer carriers under §. See
  • 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
  • Subscriber: means a person obligated under a reciprocal insurance agreement. See
  • Subscription: includes a mark, the name being written near the mark and witnessed. See Tennessee Code 1-3-105
  • Third party administrator: means any entity that, on behalf of an insurer or insurance arrangement, provides health insurance coverage to individuals in this state, receives or collects charges, contributions or premiums for, or adjudicates, processes or settles claims in connection with, any type of health benefit provided in or as an alternative to health insurance coverage. See
  • United States: includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
  • Waiting period: means , with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan. See
  • 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