Tennessee Code Annotated

Title 56: Insurance

Chapter 7: Policies and Policyholders

Part 28: Health Insurance Portability, Availability and Renewability Act

TCA 56-7-2802: Part definitions.

As used in this part, unless the context otherwise requires:

     (1)  "Affiliation period":

          (A)  Means a period that, under the terms of the health insurance coverage offered by the health maintenance organization, must expire before the health insurance coverage becomes effective. The organization is not required to provide health care services or benefits during the affiliation period and no premium shall be charged to the participant or beneficiary for any coverage during the period;

          (B)  The period shall begin on the enrollment date; and

          (C)  An affiliation period under a plan shall run concurrently with any waiting period under the plan;

     (2)  "Beneficiary" has the meaning given such term under § 3(8) of ERISA, codified in 29 U.S.C. § 1002(8);

     (3)  "Bona fide association" means, an association that:

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

          (B)  Has been formed and maintained in good faith for purposes other than obtaining insurance;

          (C)  Does not condition membership in the association on any health status-related factor relating to an individual, including an employee of an employer or a dependent of an employee;

          (D)  Makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members, or individuals eligible for coverage through a member;

          (E)  Does not make health insurance coverage offered through the association available other than in connection with a member of the association; and

          (F)  Meets additional requirements established by the commissioner;

     (4)  "Church plan" has the meaning given the term under § 3(33) of ERISA, codified in 29 U.S.C. § 1002(33);

     (5)  "COBRA continuation provision" means any of the following:

          (A)  Section 4980B of the Internal Revenue Code of 1986, codified in 26 U.S.C. § 4980B, other than subdivision (f)(1) of that section insofar as it relates to pediatric vaccines;

          (B)  ERISA, Part 6 of Subtitle B of Title I, compiled in 29 U.S.C. § 1161 et seq., other than § 609, codified in 29 U.S.C. § 1169; or

          (C)  Title XXII of the Public Health Service Act, compiled in 42 U.S.C. § 300bb-1 et seq.;

     (6)  (A)  "Creditable coverage" means, with respect to an individual, coverage of the individual under any of the following:

                (i)  A group health plan;

                (ii)  Health insurance coverage;

                (iii)  Title XVIII, Part A or Part B of the Social Security Act, known as medicare, compiled in 42 U.S.C. § 1395 et seq.;

                (iv)  Title XIX of the Social Security Act, compiled in 42 U.S.C. § 1396 et seq., other than coverage consisting solely of benefits under § 1928, codified in 42 U.S.C. § 300x-28;

                (v)  United States Code, title 10, ch. 55, 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 United States Code, title 5, ch. 89, compiled in 5 U.S.C. § 8901 et seq.;

                (ix)  A public health plan; or

                (x)  A health benefit plan under § 5(e) of the Peace Corps Act, compiled in 22 U.S.C. § 2504(e);

          (B)  Creditable coverage does not include coverage consisting solely of coverage of excepted benefits;

     (7)  "Employee" has the meaning given the term under § 3(6) of ERISA, codified in 29 U.S.C. § 1002(6);

     (8)  "Employer" has the meaning given the term under § 3(5) of ERISA, codified in 29 U.S.C. § 1002(5), except that the term includes only employers of two (2) or more employees;

     (9)  "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;

     (10)  "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;

                (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; or

                (viii)  Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits;

          (B)  Benefits not subject to requirements if offered separately:

                (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 of long-term care, nursing home care, home health care and community-based care; and

                (iii)  Other similar, limited benefits specified in regulations;

          (C)  Benefits not subject to the requirements if offered as independent, noncoordinated benefits are coverage only for a specified disease or illness and hospital indemnity or other fixed indemnity insurance; and

          (D)  Benefits not subject to the requirements if offered as a separate insurance policy are medicare supplement insurance, coverage supplemental to the coverage provided under United States Code, title 10, ch. 55, compiled in 10 U.S.C. § 1071 et seq., and similar supplemental coverage provided to coverage under a group health plan;

     (11)  "Federal governmental plan" means a governmental plan established or maintained for its employees by the federal government or by any agency or instrumentality of the federal government;

     (12)  "Governmental plan" has the meaning given the term under ERISA, § 3(32), codified in 29 U.S.C. § 1002(32), and any federal governmental plan;

     (13)  "Group health insurance coverage" means, in connection with a group health plan, health insurance coverage offered in connection with the plan;

     (14)  "Group health plan" means an employee welfare benefit plan, as defined in ERISA, § 3(1), codified in 29 U.S.C. § 1002(1), to the extent that the plan provides medical care 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. A program under which creditable coverage is provided shall be treated as a group health plan for the purposes of applying this part;

     (15)   "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;

     (16)  "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. "Health insurance issuer" does not include a group health plan;

     (17)  "Health maintenance organization" means:

          (A)  A federally qualified health maintenance organization, as defined under federal law; or

          (B)  An organization recognized under state law as a health maintenance organization;

     (18)  "Health status-related factor" means any of the following factors:

          (A)  Health status;

          (B)  Medical condition, including both physical and mental illnesses;

          (C)  Claims experience;

          (D)  Receipt of health care;

          (E)   Medical history;

          (F)  Genetic information;

          (G)  Evidence of insurability, including conditions arising out of acts of domestic violence; and

          (H)  Disability;

     (19)  "Individual health insurance coverage" means health insurance coverage offered to individuals in the individual market, but does not include short-term limited duration insurance;

     (20)  "Individual market" means the market for health insurance coverage offered to individuals other than in connection with a group health plan. This includes coverage offered in connection with a group health plan that has fewer than two (2) participants as current employees on the first day of the plan year;

     (21)  "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;

     (22)  "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;

     (23)  "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; or

          (B)  A special enrollment period;

     (24)  "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;

          (B)  Amounts paid for transportation primarily for and essential to medical care referred to in subdivision (24)(A); and

          (C)  Amounts paid for insurance covering medical care referred to in subdivisions (24)(A) and (B);

     (25)  "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;

     (26)  "Non-federal governmental plan" means a governmental plan that is not a federal governmental plan;

     (27)  "Participant" has the meaning given the term under ERISA, § 3(7), codified in 29 U.S.C. § 1002(7);

     (28)  "Placed for adoption," in connection with any placement for adoption of a child with any person, means the assumption and retention by the person of a legal obligation for total or partial support of the child in anticipation of adoption of the child. The child's placement with the person terminates upon the termination of the legal obligation;

     (29)  "Plan sponsor" has the meaning given the term under § 3(16)(B) of ERISA, codified in 29 U.S.C. § 1002(16)(B);

     (30)  "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. Genetic information shall not be treated as a preexisting condition in the absence of a diagnosis of the condition related to such information;

     (31)  "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;

     (32)  "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; and

     (33)   "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.

History: [Acts 1997, ch. 157, § 3.]