56-7-2902 - Part definitions. [Effective until June 30, 2010. See the Compiler's Notes.]
56-7-2902. Part definitions. [Effective until June 30, 2010. See the Compiler's Notes.]
As used in this part, unless the context otherwise requires:
(1) Access Tennessee means the nonprofit entity created pursuant to § 56-7-2903(a);
(2) Board means the Access Tennessee board of directors established pursuant to § 56-7-2903(b);
(3) Church plan has the meaning given the term under ERISA, in 29 U.S.C. § 1002(33);
(4) COBRA continuation coverage refers to continuation of coverage offered pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985, compiled in 42 U.S.C. § 300bb-1 et seq.;
(5) Commissioner means the commissioner of finance and administration;
(6) (A) Creditable coverage means, with respect to an individual, coverage of the individual provided under any of the following:
(i) A group health plan;
(ii) Health insurance coverage;
(iii) Part A or Part B of Title XVIII of the Social Security Act, compiled in 42 U.S.C. § 1395 et seq.;
(iv) Medicaid, other than coverage consisting solely of benefits under § 1928 of the Social Security Act, compiled in 42 U.S.C. § 1396s;
(v) The Civilian Health and Medical Program of the Uniformed Services, compiled in 10 U.S.C. § 1071 et seq.;
(vi) A medical care program of the Indian health service or of a tribal organization;
(vii) A state health benefits risk pool;
(viii) A health plan offered under the federal employees health benefits program, compiled in 5 U.S.C. § 8901 et seq.;
(ix) A public health plan as defined in federal regulations;
(x) A health benefit plan under the Peace Corps Act, codified in 22 U.S.C. § 2504(e); or
(xi) A plan described in § 56-2-121(a);
(B) A period of creditable coverage shall not be counted, with respect to the enrollment of an individual who seeks coverage under this part, if, after the period and before the enrollment date, the individual experiences a significant break in coverage;
(7) Department means the department of finance and administration;
(8) ERISA means the Employee Retirement Income Security Act of 1974, compiled in 29 U.S.C. § 1001 et seq.;
(9) 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;
(B) Whose most recent prior creditable coverage was under a group health plan, governmental plan, church plan, or plan described in § 56-2-121(a), or health insurance coverage offered in connection with the plan;
(C) Who is not eligible for coverage under a group health plan, medicare, medicaid, or any successor program, and who does not have other health insurance coverage;
(D) With respect to whom the most recent coverage within the period of aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud;
(E) Who, if offered the option of continuation of coverage under a COBRA continuation coverage provision or under a similar state program, elected the coverage; and
(F) Who has exhausted the continuation coverage described in subdivision (9)(E);
(10) Fund means the Access Tennessee health insurance pool fund established by § 56-7-2911(d);
(11) Governmental plan has the meaning under ERISA, in 29 U.S.C. § 1002(32);
(12) Group health plan means an employee welfare benefit plan as defined in ERISA, in 29 U.S.C. § 1002(1), to the extent that the plan provides medical care, as defined in subdivision (19), and including items and services paid for as medical care to employees or their dependents as defined under the terms of the plan directly or through insurance, reimbursement or otherwise;
(13) (A) 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;
(B) Health insurance coverage shall not include one (1) or more, or any combination of, the following:
(i) Coverage only for accident or disability income insurance, or any combination of accident and disability income insurance;
(ii) Coverage issued as a supplement to liability insurance;
(iii) Liability insurance, including general liability insurance and automobile liability insurance;
(iv) Workers' compensation or similar insurance;
(v) Automobile medical payment insurance;
(vi) Credit-only insurance;
(vii) Coverage for on-site medical clinics; and
(viii) Other similar insurance coverage, specified in federal regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), compiled in 42 U.S.C. § 1320d et seq., under which benefits for medical care are secondary or incidental to other insurance benefits;
(C) Health insurance coverage shall not include the following benefits, if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the coverage:
(i) Limited scope dental or vision benefits;
(ii) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or
(iii) Other similar, limited benefits specified in federal regulations issued pursuant to HIPAA;
(D) Health insurance coverage shall not include the following benefits, if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to the event under any group health plan maintained by the same plan sponsor:
(i) Coverage only for a specified disease or illness; or
(ii) Hospital indemnity or other fixed indemnity insurance; and
(E) Health insurance coverage shall not include the following, if offered as a separate policy, certificate or contract of insurance:
(i) Medicare supplemental health insurance, as defined under § 1882(g)(1) of the Social Security Act, codified in 42 U.S.C. § 1395ss(g)(1);
(ii) Coverage supplemental to the coverage provided under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), compiled in 10 U.S.C. § 1071 et seq.; or
(iii) Similar supplemental coverage provided to coverage under a group health plan;
(14) Health maintenance organization means an organization as defined in § 56-32-102;
(15) Hospital means a licensed public or private institution as defined in § 68-11-201;
(16) 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 § 56-2-121(a);
(17) Insurer means any entity that provides health insurance coverage in this state. For the purposes of this part, insurer includes, but is not limited to, an insurance company, a health maintenance organization, a preferred provider organization, a hospital and medical service corporation, a surplus lines insurer, an insurer providing stop-loss or excess loss insurance to a group health plan, a reinsurer reinsuring health insurance in this state, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation;
(18) 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.S.C. § 1396 et seq., and any waivers thereof;
(19) Medical care means:
(A) The diagnosis, care, mitigation, treatment, or prevention of disease;
(B) Transportation primarily for and essential to medical care referred to in subdivision (19)(A); and
(C) Insurance covering medical care referred to in subdivisions (19)(A) and (B);
(20) Medicare means coverage under Parts A and/or B of Title XVIII of the Social Security Act, compiled in 42 U.S.C. § 1395 et seq.;
(21) Plan of operation means the articles, bylaws, and operating rules and procedures adopted by the board pursuant to § 56-7-2903(i);
(22) Pool means the Access Tennessee health insurance pool, created in § 56-7-2903(a);
(23) Resident means an individual who is legally domiciled in Tennessee;
(24) 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;
(25) 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; and
(26) Unfair referral means a referral to the pool described in § 56-7-2908(g).
[Acts 2006, ch. 867, §§ 3, 14(a).]