Title 56, Insurance

(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 offic…

(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) (1) Every enrollee residing in this state is entitled to evidence of coverage.(2) No evidence of coverage, or amendment to the evidence of coverage, shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage, or amendment to …

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 c…

Every HMO shall provide promptly to its enrollees notice of any material change in the operation of the organization that will affect them directly.

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 oth…

(a) To ensure the public's interest in the delivery of health care services by fiscally sound HMOs, each HMO must provide the commissioner evidence of compliance with the following minimum net worth requirements:(1) Before issuing any certificate of authority, the commissioner sh…

(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 …

(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. “Agen…

(a) The commissioner of commerce and insurance, in cooperation with the commissioner of health, shall coordinate the regulation of any HMO holding a certificate of authority to ensure the financial viability of the HMO and that the HMO is currently providing and shall in the futu…

(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 ma…

(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 tit…

(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 deni…

(1) 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 dollar…

(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 …

(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 s…

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…

(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 employ…

(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…

(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) o…

(a) HMOs shall be subject to the same requirements regarding prompt payment of claims, and the additional liability for bad faith failure to pay claims promptly, as are applicable to insurance companies under § 56-7-105. (b) This subsection (b) is intended to ensure the prompt an…

(a) As used in this section, “managed health insurance issuer” means an entity that:(1) Offers health insurance coverage or benefits under a contract that restricts reimbursement for covered services to a defined network of providers; and(2) Is regulated under this title or is an…

(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 un…

(a) A managed health insurance issuer shall not terminate or nonrenew a contract with a health care provider, or take other retaliatory action against a health care provider, because the provider:(1) Communicated with an enrollee with respect to the enrollee's health status, heal…

(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 sh…

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,…

(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 i…

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.

A violation of this chapter shall subject the violator to the penalty contained in § 56-1-801.

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 basi…

(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 Te…