reglab/statecodes huggingface dataset:
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 31 - VISION SERVICE PLAN LAW (§§ 56-31-101 — 56-31-131) › Section 56-31-129 - Settlement of dispute or controversy by commissioner - Review of decision

Any dispute or controversy arising between a vision service plan corporation and any participating optometrist, or any optometrist desiring to become a participating optometrist, or any subscriber, or any other person whose subscription certificate has been cancelled, or to whom the corporation has refused to issue a certificate, may, within thirty (30) days after the dispute or controversy arises, be appealed to the commissioner, by the person allegedly aggrieved, or a person or persons designated by that person. After proper notice and hearing, the commissioner shall make a finding, which shall be binding on any vision service plan corporation or agent of the corporation, subject to judicial review.
Acts 1969, ch. 118, § 29; T.C.A., § 56-3729.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 31 - VISION SERVICE PLAN LAW (§§ 56-31-101 — 56-31-131) › Section 56-31-130 - Construction of chapter

This chapter is not to be construed as prohibiting any insurance company, properly qualified in this state to write accident or health or disability insurance, from making available any plan of vision service that may be approved by the commissioner under existing statutes or within the authority granted to benevolent associations.
Acts 1969, ch. 118, § 30; T.C.A., § 56-3730.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 31 - VISION SERVICE PLAN LAW (§§ 56-31-101 — 56-31-131) › Section 56-31-131 - Laws relating to practice of medicine or surgery or optometry or other insurance not affected

Nothing in this chapter shall be construed to modify or repeal any law, or parts of law, now in force relating to the practice of medicine or surgery, or to the practice of optometry, or to the regulation of life, accident, health or casualty insurance, except as it is inconsistent with this chapter.
Acts 1969, ch. 118, § 31; T.C.A., § 56-3731.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-101 - Short title

This chapter shall be known and may be cited as the "Health Maintenance Organization Act of 1986."
Acts 1986, ch. 713, § 1; T.C.A. § 56-32-201.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-105 - Powers - Limitations - Hold harmless clause

(a)
The powers of an HMO include, but are not limited to, the following:
(1)
The purchase, lease, construction, renovation, operation or maintenance of hospitals or medical facilities, or both, and their ancillary equipment, and property reasonably required for its principal office or for purposes necessary in the transaction of the business of the organization;
(2)
The making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation or corporation under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing health care services to enrollees;
(3)
The furnishing of health care services through providers that are under contract with or employed by the HMO;
(4)
The contracting with any person for the performance on its behalf of certain functions, such as marketing, enrollment and administration;
(5)
The contracting with an insurance company licensed in this state, or with a hospital or medical service corporation authorized to do business in this state, for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the HMO; and
(6)
The offering of other health care services, in addition to basic health care services.
(b)
An HMO shall file notice, with adequate supporting information, with the commissioner prior to the exercise of any power granted in subdivision (a)(1), (a)(2) or (a)(4), if the dollar amount resulting from such action would exceed twenty-five percent (25%) of surplus. The commissioner shall disapprove the exercise of power only if in the commissioner's opinion it would substantially and adversely affect the financial soundness of the HMO and endanger its ability to meet its obligations. If the commissioner does not disapprove within thirty (30) days of the filing, it shall be deemed approved.
(c)
All provider contracts must include a hold harmless clause that will relieve any enrollee of a licensed HMO from any liability for services rendered by the providers except for reasonable copayment and uncovered expenses.
Acts 1986, ch. 713, § 5; T.C.A. § 56-32-205.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-106 - Fiduciaries - Bonds

(a)
Any director, officer, employee or partner of an HMO who receives, collects, disburses or invests funds in connection with the activities of the organization shall be responsible for the funds in a fiduciary relationship to the organization.
(b)
An HMO shall maintain in force a fidelity bond on employees and officers in an amount not less than one hundred thousand dollars ($100,000) or such other sum as prescribed by the commissioner. The bonds shall be written with at least a one-year discovery period and, if written with at least a three-year discovery period, shall contain a provision that no cancellation or termination of the bond, whether by or at the request of the insured or by the underwriter, shall take effect prior to the expiration of ninety (90) days after written notice of the cancellation or termination has been filed with the commissioner, unless an earlier date of cancellation or termination is approved by the commissioner.
Acts 1986, ch. 713, § 6; T.C.A. § 56-32-206.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-108 - Reports

Every HMO shall annually, on or before March 1, file with the commissioner a report on the blank prescribed by the National Association of Insurance Commissioners for HMOs. The commissioner may require additional reports deemed reasonably necessary and appropriate to enable the commissioner to carry out the commissioner's duties under this chapter.
Acts 1986, ch. 713, § 8; T.C.A. § 56-32-208.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-109 - Notice of change in operation

Every HMO shall provide promptly to its enrollees notice of any material change in the operation of the organization that will affect them directly.
Acts 1986, ch. 713, § 9; T.C.A. § 56-32-209.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-110 - [Repealed]

Acts 1986, ch. 713, §10; 1997 , ch. 416, § 1; T.C.A. §56-32-210, repealed by Acts 2010 , ch. 980, § 27, effective 1/1/2011.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-111 - Investments

With the exception of investments made in accordance with §
56-32-105
, the funds of an HMO shall be invested only in securities or other investments permitted by the laws of this state for the investment of assets constituting the legal reserves of life insurance companies or other securities or investments that the commissioner permits.
Acts 1986, ch. 713, § 11; T.C.A. § 56-32-211.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-113 - Prohibited practices

(a)
No HMO or representative of the HMO may cause or knowingly permit the use of advertising that is untrue or misleading, solicitation that is untrue or misleading, or any form of evidence of coverage that is deceptive. For the purpose of this chapter:
(1)
A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect that is or may be significant to an enrollee of, or person considering enrollment with, an HMO;
(2)
A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage or possible significance to an enrollee of, or person considering enrollment in, an HMO, if the benefit or advantage or absence or limitation, exclusion or disadvantage does not in fact exist; and
(3)
An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, is such as to cause a reasonable person, not possessing special knowledge regarding HMOs and evidences of coverage for HMOs, to expect benefits, services, charges or other advantages that the evidence of coverage does not provide or that the HMO issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage.
(b)
Chapter 8, part 1 of this title shall be construed to apply to HMOs and evidences of coverage, except to the extent that the commissioner determines the nature of HMOs and evidences of coverage render chapter 8, part 1 of this title inappropriate.
(c)
An HMO may not cancel or refuse to renew an enrollee, except for reasons stated in the organization's rules applicable to all enrollees, or for the failure to pay the charge for coverage, or for other reasons promulgated by the commissioner.
(d)
No HMO, unless licensed as an insurer, may refer to itself as an insurer or use a name deceptively similar to the name or description of any insurance or surety corporation doing business in this state.
(e)
Any person not in possession of a valid certificate of authority issued pursuant to this chapter may not use the phrase "health maintenance organization" or "HMO" in the course of operation.
Acts 1986, ch. 713, § 13; T.C.A. § 56-32-213.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-114 - Licensing of agents

(a)
The commissioner may, after notice and hearing, promulgate reasonable rules and regulations necessary to provide for the licensing of agents. "Agent" means a person who is appointed or employed by an HMO and who engages in solicitation or membership in the organization. "Agent" does not include a person enrolling members on behalf of an employer, union or other organization to whom a master subscriber contract has been issued.
(b)
The commissioner may by rule exempt certain classes of persons from the requirement of obtaining a license, if other existing licensing procedures make a separate HMO agent's license unnecessary.
Acts 1986, ch. 713, § 14; T.C.A. § 56-32-214.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-116 - Revocation or suspension of certificates

(a)
The commissioner may suspend or revoke any certificate of authority issued to an HMO under this chapter if the commissioner finds that any of the following conditions exist:
(1)
The HMO is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under §
56-32-103
, unless amendments to the submissions have been filed with and approved by the commissioner;
(2)
The HMO issues evidence of coverage or uses a schedule of charges for health care services that do not comply with the requirements of §
56-32-107
;
(3)
The HMO does not provide or arrange for basic health care services;
(4)
The HMO is unable to fulfill its obligations to furnish health care services;
(5)
The HMO is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(6)
The HMO has failed to implement the complaint system required by §
56-32-110
[repealed] in a reasonable manner to resolve complaints;
(7)
The HMO, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;
(8)
The continued operation of the HMO would be hazardous to its enrollees;
(9)
The HMO has otherwise failed substantially to comply with this chapter; or
(10)
The HMO has filed with the department sworn financial statements that contain material omissions or errors.
(b)
A certificate of authority shall be suspended or revoked only after compliance with the requirements of §
56-32-118
.
(c)
When the certificate of authority of an HMO is suspended, the HMO shall not, during the period of suspension, enroll any additional enrollees, except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.
(d)
When the certificate of authority of an HMO is revoked, the HMO shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the HMO. It shall engage in no further advertising or solicitation whatsoever. The commissioner may, by written order, permit such further operation of the organization as the commissioner may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practicable opportunity to obtain continuing health care coverage.
Acts 1986, ch. 713, § 16; 2004, ch. 507, § 7; T.C.A. § 56-32-216.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-117 - Rehabilitation, liquidation, conservation or supervision of HMOs

(a)
Any rehabilitation, liquidation, conservation or supervision of an HMO shall be deemed to be the rehabilitation, liquidation, conservation or supervision of an insurance company and shall be conducted under the supervision of the commissioner pursuant to chapter 9 of this title. The commissioner may apply for an order directing the commissioner to rehabilitate, liquidate, conserve or supervise an HMO upon any one (1) or more grounds set out in chapter 9 of this title, or when in the commissioner's opinion the continued operation of the HMO would be hazardous either to the enrollees or to the people of this state. Enrollees shall have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer.
(b)
A claim by a health care provider for an uncovered expenditure has the same priority as an enrollee; provided, that the provider of services agrees not to assert the claim against any enrollee of the HMO.
(c)
(1)
For the purposes of supervision, rehabilitation, or liquidation of HMOs that participate in the TennCare program under Title XIX of the federal Social Security Act (
42 U.S.C. § 1396
et seq.), or any successor to the TennCare program, and in addition to the powers and duties set forth in this chapter, the department or the chancery court shall have the power to examine and investigate the affairs of every person, entity, HMO, an affiliate of the parent of the HMO, or an affiliate of the HMO, in order to determine whether the person, entity, HMO, an affiliate of the parent of the HMO, or an affiliate of the HMO, is operating in accordance with this chapter and title 71, chapter 5. For purposes of this subdivision (c)(1), "affiliate" means any entity that exercises control over or is controlled by the HMO, directly or indirectly through:
(A)
Equity ownership of voting securities;
(B)
Common managerial control; or
(C)
Collusive participation by the management of the HMO and affiliate in the management of the HMO or the affiliate.
(2)
For purposes of subdivision (c)(1), "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.
Acts 1986, ch. 713, § 17; 1999, ch. 322, §§ 4, 7; 2000, ch. 708, §§ 1, 7; T.C.A. § 56-32-217.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-118 - Rules and regulations - Notice of hearing for denial, revocation or suspension of certificates - Administrative procedure

(a)
The commissioner of commerce and insurance and the commissioner of health may, after notice and hearing, promulgate reasonable rules and regulations, as are necessary or proper to carry out this chapter.
(b)
When the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, the commissioner shall notify the HMO in writing specifically stating the grounds for denial, suspension or revocation and fixing a time of at least thirty (30) days thereafter for a hearing on the matter.
(c)
The Uniform Administrative Procedures Act, compiled in title 4, chapter 5, shall apply to proceedings under this section.
Acts 1986, ch. 713, §18; 1997 , ch. 60, § 3; T.C.A. § 56-32-218.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-119 - Fees

Every HMO subject to this chapter shall pay to the commissioner the following fees for:
(1)
Filing an application for certificate of authority, one thousand three hundred dollars ($1,300);
(2)
Filing an amendment to the organization documents that require approval, sixty dollars ($60.00);
(3)
Filing each annual report, one hundred ninety-five dollars ($195); and
(4)
Renewal of the certificate of authority each year, four hundred forty-five dollars ($445).
Acts 1986, ch. 713, § 19; 2001, ch. 333, § 6; T.C.A. § 56-32-219.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-120 - Administrative penalty - Cease and desist orders - Injunctions

(a)
The commissioner may, in lieu of suspension or revocation of a certificate of authority under §
56-32-118
, levy an administrative penalty in an amount not less than one thousand dollars ($1,000) nor more than ten thousand dollars ($10,000), if reasonable notice in writing is given of the intent to levy the penalty and the HMO has a reasonable time within which to remedy the defect in its operations that gave rise to the penalty citation. The commissioner may augment this penalty by an amount equal to the sum that the commissioner calculates to be the damages suffered by enrollees or other members of the public.
(b)
(1)
The commissioner may issue an order directing an HMO or a representative of an HMO to cease and desist from engaging in any act or practice in violation of this chapter.
(2)
Within fifteen (15) days after service of the cease and desist order, the respondent may request a hearing on the question of whether acts or practices in violation of this chapter have occurred. The hearings shall be conducted pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
(c)
In the case of any violation of this chapter, if the commissioner elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued pursuant to subsection (b), the commissioner may institute a proceeding to obtain injunctive or other appropriate relief in the chancery court of Davidson County.
Acts 1986, ch. 713, § 20; T.C.A. § 56-32-220.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-121 - Applicability of other laws - Construction

(a)
Except as otherwise provided in this chapter, the insurance laws and the hospital or medical service corporation laws are not applicable to any HMO granted a certificate of authority under this chapter. This subsection (a) does not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance law or the hospital or medical service corporation laws of this state, except with respect to its HMO activities authorized and regulated pursuant to this chapter.
(b)
Solicitation of enrollees by an HMO granted a certificate of authority, or its representatives, shall not be construed to violate any law relating to solicitation or advertising by health professions.
(c)
Any HMO authorized under this chapter shall not be deemed to be practicing medicine and shall be exempt from title 63, chapter 6, relating to the practice of medicine.
(d)
The Insurance Holding Company System Act of 1986, compiled in chapter 11 of this title, shall be applicable to HMOs to the extent provided in that act, and to the extent provided in §
56-32-122
.
(e)
HMOs providing utilization review services for mental health and chemical dependency care for their own enrollees shall be subject to chapter 6, part 7 of this title, regarding the provision of utilization review services for mental health or chemical dependency care. This subsection (e) shall not apply to utilization review services provided to TennCare enrollees.
Acts 1986, ch. 713, § 21; 2000, ch. 708, §3b; 2003 , ch. 58, § 1; T.C.A. § 56-32-221.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-122 - Acquisition of control of or merger of an HMO

No person may make a tender for or a request or invitation for tenders of, or enter into an agreement to exchange securities for or acquire in the open market or otherwise, any voting security of an HMO or enter into any other agreement if, after the consummation of the agreement, that person would, directly or indirectly, or by conversion or by exercise of any right to acquire, be in control of the HMO, and no person may enter into an agreement to merge or consolidate with or otherwise to acquire control of an HMO, unless, at the time any offer, request or invitation is made or any agreement is entered into, or prior to the acquisition of the securities if no offer or agreement is involved, the person has filed with the commissioner and has sent to the HMO, information required by §
56-11-103(b)(1)-(5) and (13)
, and the offer, request, invitation, agreement or acquisition has been approved by the commissioner. Approval by the commissioner shall be governed by §
56-11-103(d)(1) and (2)
.
Acts 1986, ch. 713, § 22; 1993, ch. 253, § 15; 2000, ch. 708, § 3a; T.C.A. § 56-32-222.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-123 - Bidding

(a)
Each employer, public or private, except any public entity that has a metropolitan form of government and a population of not less than four hundred thousand (400,000), according to the 1980 federal census or any subsequent federal census, in this state that offers its employees a health benefit plan and employs not less than twenty-five (25) employees, shall afford at least two (2) qualified HMOs the opportunity to bid or to provide health care services. This dual offering is contingent upon written requests being received from the HMOs for inclusion in the employer's health benefit plan, and provided the HMOs are different types or models, such as medical group or staff and individual practice association. Where there is a prevailing collective bargaining agreement, the selection of the HMO or organizations to be made available to the employees shall be made under the agreement.
(b)
No employer in this state shall be required to pay more for health benefits as a result of the application of this section than would otherwise be required by any prevailing collective bargaining agreement or other contract for the provision of health benefits to its employees; provided, that the employer or benefits fund shall pay to the HMO chosen by each employee or member an amount equal to the lesser of:
(1)
The amount paid on behalf of its other employees or members for health benefits; or
(2)
The HMO's charge for coverage approved by the commissioner pursuant to §
56-32-107
.
Acts 1986, ch. 713, § 23; 1989, ch. 187, § 1; T.C.A. § 56-32-223.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-124 - Taxation

(a)
All HMOs doing business in this state shall pay tax on the gross amount of all dollars collected from an enrollee or on an enrollee's behalf in the amount of six percent (6%).
(b)
The taxes provided for in this section shall be due and payable in an electronic format approved by the commissioner on a quarterly basis with payments being due and payable on June 1, August 20, December 1 and March 1. Any company failing or refusing to render tax statement information or to pay taxes as specified in this section shall be subject to §
56-4-216
.
(c)
The amount of taxes collected under this section shall be a single credit against the sum total of the taxes imposed by the Franchise Tax Law, compiled in title 67, chapter 4, part 21, and by the Excise Tax Law, compiled in title 67, chapter 4, part 20.
Acts 1986, ch. 713, § 24; 1995, ch. 303, § 1; T.C.A. §
56-32-224
; Acts 2009, ch. 531, § 12; 2015, ch. 362, § 1; 2015, ch. 155, § 19.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-125 - Confidentiality of information

(a)
Any data or information pertaining to the diagnosis, treatment or health of any enrollee or applicant obtained from the person or from any provider by any HMO shall be held in confidence by the HMO and shall not be disclosed by the HMO to any person, except upon any one (1) of the following circumstances:
(1)
To the extent that it may be necessary to carry out the purposes of this chapter;
(2)
Upon the express consent of the enrollee or applicant;
(3)
In the event of a claim or litigation between an enrollee or applicant and the HMO wherein the data or information is pertinent;
(4)
To implement the purposes of title 71, chapter 5; or
(5)
When the data or information is required to be disclosed by the authority of another statute.
(b)
Nothing in this section shall be construed to amend §
63-1-150
regarding confidentiality of records and statements relating to quality improvement committees of the HMO that shall remain privileged and not subject to subpoena or discovery.
Amended by 2017 Tenn. Acts, ch. 4,s 3, eff. 3/15/2017.
Acts 1986, ch. 713, § 26; T.C.A. § 56-32-225.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-127 - [Repealed]

Acts 1998, ch. 952, §§ 1, 2; 1999, ch. 244, §§ 1 - 4; T.C.A. §56-32-227, repealed by Acts 2010 , ch. 980, § 28, effective 1/1/2011.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-129 - Prohibited discrimination

(a)
The managed health insurance issuer shall not discriminate with respect to participation, referral, reimbursement of covered services or indemnification as to any provider within a class of providers who is acting within the scope of the provider's license or certification under state law, solely on the basis of the license or certification. In selecting among providers of health services for membership in a provider network, the managed health insurance issuer or other network shall not discriminate against a class of providers who provide services that are covered by the plan by prohibiting the class of providers from membership in the provider network. This section shall not be construed as prohibiting managed health insurance issuers from including providers or classes of providers only to the extent necessary to meet the needs of the managed health insurance issuer's plan and its enrollees, or from limiting referrals or establishing any other measure designed to maintain quality and control costs consistent with the responsibilities of the plan. This chapter shall not be construed as creating coverage for any service that is not otherwise covered under the terms of the managed health insurance issuer's plan.
(b)
As used in this section, "class of providers" means optometrists, ophthalmologists, podiatrists, pharmacists, and chiropractors.
Amended by 2017 Tenn. Acts, ch. 82,s 1, eff. 7/1/2017.
Acts 1998, ch. 1033, § 6; 2002, ch. 641, § 1; T.C.A. § 56-32-229.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-131 - Verification of health benefit delivery - Annual review - Survey of persons disenrolled by the TennCare program

(a)
It is the intent of this section to establish a procedure to verify that the HMOs and behavioral health organizations participating by contract in the TennCare program are delivering the health benefits required under their TennCare contracts with the state. This procedure shall also assure that each of these entities have adequate provider networks to ensure the effective and efficient delivery of health care services to TennCare enrollees.
(b)
The commissioner, with the advice and consent of the office of the comptroller of the treasury, shall contract with an entity independent of the state of Tennessee to conduct annual reviews of organizations contracting with the state in the TennCare program. The contract shall be entered into in accordance with appropriate state procedures. The purpose of this contract shall be to verify, on an annual basis, that each HMO and behavioral health organization contracting with the state of Tennessee in the TennCare program is delivering health care services in conformity with the TennCare contract and applicable statutory authority. This annual review shall include verifying that each of these organizations maintains an adequate network. The standards for network adequacy are defined by the TennCare contract and applicable statutes and regulations. Nothing in this subsection (b) precludes the expansion of the state's current contract with its External Quality Review Organization (EQRO) to include having the EQRO conduct this review. The contractor shall submit all findings for each organization in writing to the commissioner, the comptroller of the treasury and the director of the TennCare bureau.
(c)
The department of commerce and insurance is authorized to conduct a survey of persons disenrolled by the TennCare program to determine if the persons were able to procure health insurance in the private market, or otherwise had access to healthcare benefits. The survey will not commence until a survey form is developed with the assistance of the TennCare bureau of the department of finance and administration, adopted by the commissioner of commerce and insurance, and approved by the state comptroller of the treasury. The survey will be conducted of persons who were disenrolled during the period from January 1, 2002, to December 31, 2002.
Acts 1999, ch. 322, § 1; 2002, ch. 874, § 1; T.C.A. § 56-32-231.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-132 - Investigatory powers of the department of commerce and insurance

For the purposes of regulation and oversight of HMOs that participate in the TennCare program under Title XIX of the federal Social Security Act (
42 U.S.C. § 1396
et seq.), or any successor to the TennCare program, and in addition to the powers and duties set forth in this title, the department of commerce and insurance has the power to examine and investigate the affairs of every person, entity, HMO, an affiliate of the parent of the HMO, or an affiliate of the HMO, in order to determine whether the person, entity, HMO, an affiliate of the parent of the HMO, or an affiliate of the HMO, is operating in accordance with this chapter and title 71, chapter 5.
Acts 1999, ch. 322, § 2; T.C.A. § 56-32-232.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-134 - Required information for verification and audit purposes

(a)
As used in this section, "affiliate" has the same meaning as defined in §
56-32-102
.
(b)
(1)
For verification and audit purposes, each managed care organization that participates in the TennCare program shall provide to the department of commerce and insurance the following information for its organization:
(A)
The names and addresses of all persons required to file a disclosure with the commissioner of health under §
71-5-137(a) and (b)
;
(B)
An explanation of the interest in or connection with the managed care organization, or an affiliate of the organization, in accordance with §
71-5-137(a)
, of each person required to file a disclosure under subdivision (b)(1)(A); and
(C)
A listing of all compensation of any form paid to each person required to file a disclosure under subdivision (b)(1)(A) related to the person's interest in or connection with the managed care organization, or an affiliate of the organization, in accordance with §
71-5-137(a)
.
(2)
The information shall be provided on or before January 15 of each year for the preceding calendar year.
Acts 2000, ch. 708, § 5; T.C.A. § 56-32-234.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-135 - Confidentiality

Any information and documentation obtained by the department pursuant to §
56-32-117(c)
or §
56-32-132
, shall be considered confidential, unless the commissioner in the commissioner's sole discretion determines to disclose the information or documentation.
Acts 2000, ch. 708, § 8; T.C.A. § 56-32-235.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-136 - Violation and penalty

A violation of this chapter shall subject the violator to the penalty contained in §
56-1-801
.
Acts 2000, ch. 708, § 8; T.C.A. § 56-32-236.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-137 - Discrimination prohibited - Coverage not created

A managed health insurance issuer shall not discriminate with respect to participation, referral, reimbursement of covered services, or indemnification as to any provider who is acting within the scope of the provider's license or certification under state law, solely on the basis of the license or certification. In selecting among providers of health services for membership in a provider network, a managed health insurance issuer or other network shall not discriminate against a class of providers who provide services that are covered by the plan by prohibiting the class of providers from membership in the provider network. As used in this section, "class of providers" means licensed physician assistants as defined in §
63-19-102
, certified nurse midwives as described in §
56-7-2407
, and nurses in advanced practice as defined in §
56-7-2408
. This section shall not be construed as prohibiting managed health insurance issuers from including providers or classes of providers only to the extent necessary to meet the needs of the managed health insurance issuer's plan and its enrollees or from limiting referrals or establishing any other measure designed to maintain quality and control costs consistent with the responsibilities of the plan. This section shall not be construed as creating coverage for any service that is not otherwise covered under the terms of the managed health insurance issuer's plan.
Acts 2001, ch. 88, § 1; 2002, ch. 554, § 1; T.C.A. § 56-32-237.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 32 - HEALTH MAINTENANCE ORGANIZATION ACT OF 1986 (§§ 56-32-101 — 56-32-138) › Section 56-32-138 - Payment of authorized pharmacy claims - Corrections by pharmacy

(a)
(1)
If authorization is given and a pharmacy claim is adjudicated by an HMO or its agent to any pharmacy services provider for care to be delivered to a covered beneficiary under any evidence of coverage issued by the HMO, including those organizations participating in the TennCare program, collectively referred to as "organization," then the organization acting directly or by delegation through an agent acting on behalf of the organization shall not subsequently rescind or modify that authorization or deny the authorized payment to the pharmacy services provider for the authorized service after the provider renders the authorized service in good faith and pursuant to the authorization, except for payments made as a result of the provider's misrepresentation or fraud.
(2)
If the bureau of TennCare provides notice to the HMO or its agent that a person is eligible to participate in the TennCare program, and, if based on good faith reliance on the information, the HMO makes a payment to a pharmacy provider for providing pharmacy services to the person enrolled in the TennCare program, and if the bureau of TennCare later rescinds the eligibility for the person, then the bureau of TennCare shall remain liable to the HMO for any amount the HMO paid to the provider for the pharmacy services. The bureau of TennCare shall not be liable when the eligibility is rescinded in the case of fraud or death as defined in the contract. The bureau of TennCare shall not be liable due to an error or delay on the part of the managed care organization or its agents in processing eligibility information received from the bureau of TennCare.
(b)
Notwithstanding subsection (a), any organization may request the pharmacy to adjust or correct an adjudicated claim to correct incorrect data elements, including incorrect billing units, incorrect national drug code (NDC) numbers and incorrect prescriber identification numbers submitted in error and in good faith by the pharmacy. An organization shall provide the pharmacy an opportunity to correct claims submitted by the pharmacy in good faith. If the pharmacy does not correct the adjudicated claim requested within thirty (30) days of receipt of the request, then the organization may rescind, modify or recoup the funds paid on the requested claim and shall not be in violation of this section.
Acts 2001, ch. 340, § 1; T.C.A. § 56-32-238.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 33 - TRAVEL INSURANCE (§§ 56-33-101 — 56-33-109) › Section 56-33-101 - Applicability and scope

(a)
This chapter applies to travel insurance:
(1)
That covers a resident of this state and is sold, solicited, negotiated, or offered in this state; and
(2)
Policies and certificates that are delivered or issued for delivery in this state.
(b)
This chapter does not apply to cancellation fee waivers or travel assistance services, except as expressly provided in this chapter.
Acts 2022, ch. 703, § 6.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 33 - TRAVEL INSURANCE (§§ 56-33-101 — 56-33-109) › Section 56-33-103 - Travel protection plans

Travel protection plans may be offered for one (1) price for the combined features that the travel protection plan offers in this state if, at or prior to the time of purchase:
(1)
The travel protection plan clearly discloses to the consumer that it includes travel insurance, travel assistance services, and cancellation fee waivers as applicable;
(2)
The person offering the plan provides information and an opportunity for the consumer to obtain additional information regarding the features and pricing; and
(3)
The written materials provided:
(A)
Describe and delineate the travel insurance, travel assistance services, and cancellation fee waivers in the travel protection plan; and
(B)
Include the travel insurance disclosures, contact information for a person providing travel assistance services, and cancellation fee waivers, as applicable.
Acts 2022, ch. 703, § 6.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 33 - TRAVEL INSURANCE (§§ 56-33-101 — 56-33-109) › Section 56-33-104 - Fulfillment materials - Cancellation - Negative option or opt-out prohibited

(a)
(1)
As used in this section, "delivery" means handing fulfillment materials to the policyholder or certificate holder, or sending fulfillment materials by postal mail or electronic means to the policyholder or certificate holder.
(2)
Documents provided to consumers prior to the purchase of travel insurance, including sales materials, advertising materials, and marketing materials, must be consistent with the travel insurance policy itself, including forms, endorsements, policies, rate filings, and certificates of insurance.
(3)
For travel insurance policies or certificates that contain pre-existing condition exclusions, information and an opportunity to learn more about the pre-existing condition exclusions must be provided:
(A)
Prior to the time of purchase; and
(B)
In the coverage's fulfillment materials.
(4)
(A)
The fulfillment materials and the information described in §
56-6-1403(a)(2)(A)(i)-(iv)
must be provided to a policyholder or certificate holder as soon as practicable, following the purchase of a travel protection plan.
(B)
Unless the insured has started a covered trip or filed a claim under the travel insurance coverage, a policyholder or certificate holder may cancel a policy or certificate for a full refund of the travel protection plan price from the date of purchase of a travel protection plan until at least:
(i)
Fifteen (15) days following the date of delivery of the travel protection plan's fulfillment materials by postal mail; or
(ii)
Ten (10) days following the date of delivery of the travel protection plan's fulfillment materials by means other than postal mail.
(5)
The person shall disclose in the policy documentation and fulfillment materials whether the travel insurance is primary or secondary to other applicable coverage.
(6)
If travel insurance is marketed directly to a consumer through an insurer's website or by another through an aggregator site, then it is not an unfair trade practice or other violation of law to provide an accurate summary or short description of coverage on the web page, if the consumer has access to the full provisions of the policy through electronic means.
(b)
(1)
A person offering, soliciting, or negotiating travel insurance or travel protection plans on an individual or group basis shall not do so by using a negative option or opt-out.
(2)
As used in this subsection (b), "negative option or opt-out" means an option that requires a consumer to take an affirmative action to deselect coverage when the consumer purchases a trip, such as unchecking a box on an electronic form.
Acts 2022, ch. 703, § 6.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 33 - TRAVEL INSURANCE (§§ 56-33-101 — 56-33-109) › Section 56-33-105 - Requirement to choose options as condition of purchasing trip or travel package

Notwithstanding §
56-8-104
, if a consumer's destination jurisdiction requires insurance coverage, then it is not an unfair trade practice to require a consumer to choose between the following options as a condition of purchasing a trip or travel package:
(1)
Purchasing the coverage required by the destination jurisdiction through the travel retailer or limited lines travel insurance producer supplying the trip or travel package; or
(2)
Agreeing to obtain and provide proof of coverage that meets the destination jurisdiction's requirements prior to departure.
Acts 2022, ch. 703, § 6.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 33 - TRAVEL INSURANCE (§§ 56-33-101 — 56-33-109) › Section 56-33-106 - Travel administrator for travel insurance

(a)
Notwithstanding another provision of this title to the contrary, a person shall not act or represent themself as a travel administrator for travel insurance in this state unless that person:
(1)
Is a licensed property and casualty insurance producer or accident and health insurance producer in this state for activities permitted under that producer license;
(2)
Holds a valid managing general agent (MGA) license in this state; or
(3)
Holds a valid third-party administrator (TPA) license in this state.
(b)
(1)
An insurer is responsible for:
(A)
The acts of a travel administrator administering travel insurance underwritten by the insurer; and
(B)
Ensuring that the travel administrator maintains all books and records relevant to the insurer.
(2)
The travel administrator must make the books and records relevant to an insurer available to the commissioner upon request.
Acts 2022, ch. 703, § 6.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 33 - TRAVEL INSURANCE (§§ 56-33-101 — 56-33-109) › Section 56-33-107 - Classification and filing of travel insurance - Form of travel insurance - Eligibility and underwriting standards for travel insurance

(a)
(1)
Notwithstanding a provision of this title to the contrary, travel insurance must be classified and filed for purposes of rates and forms under an inland marine line of insurance.
(2)
Travel insurance that provides coverage for sickness, accident, disability, or death occurring during travel, either exclusively or in conjunction with related coverages of emergency evacuation or repatriation of remains, may be filed under either an accident and health line of insurance or an inland marine line of insurance.
(b)
Travel insurance may be in the form of an individual, group, or blanket policy.
(c)
Eligibility and underwriting standards for travel insurance may be developed and provided based on travel protection plans designed for individual or identified marketing or distribution channels, if the standards also meet the state's underwriting standards for inland marine lines of insurance.
Acts 2022, ch. 703, § 6.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 33 - TRAVEL INSURANCE (§§ 56-33-101 — 56-33-109) › Section 56-33-108 - Cancellation fee waivers and travel assistance services exempt from insurance laws

Cancellation fee waivers and travel assistance services governed under this chapter are not insurance and are exempt from the insurance laws of this state.
Acts 2022, ch. 703, § 6.
2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 33 - TRAVEL INSURANCE (§§ 56-33-101 — 56-33-109) › Section 56-33-109 - Promulgation of rules

The commissioner is authorized to promulgate rules to effectuate this chapter. The rules must be promulgated in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
Acts 2022, ch. 703, § 6.