(b) A federally defined eligible individual who has not experienced a significant break in coverage and who is and continues to be a resident shall be eligible for pool coverage.
(c) To the extent allowed under federal law, the board may establish eligibility criteria to provide pool coverage for individuals not specified in subsection (a).
(1) (A) In the first twelve (12) months of the pool's operation, the criteria shall include, with respect to individuals who are not federally defined eligible individuals:
(i) A requirement that an individual be a resident of Tennessee for at least six (6) months;
(ii) A requirement that an individual not have had health insurance coverage in the previous six (6) months;
(iii) A requirement that an individual not have access to health insurance coverage at the time of application to the pool;
(iv) A requirement that an individual exhaust any option of continuation coverage under a group or individual health insurance plan, including COBRA continuation coverage; and
(v) A requirement that the person not have coverage pursuant to § 56-7-2809.
(B) The board shall establish procedures to verify that the criteria in subdivisions (c)(1)(A)(i)-(v) have been met.
(2) At the end of the first year of the pool's operation, or any time thereafter, the board may assess the implementation and impact of the eligibility criteria established in subdivision (c)(1) and modify the criteria as it deems appropriate.
(3) The board may establish additional eligibility criteria to provide pool coverage for individuals who are not federally defined eligible individuals. The criteria may include:
(A) A list of medical or health conditions for which a person shall be eligible for pool coverage without applying for health insurance;
(B) A requirement that an individual be uninsured for a specified period of time prior to obtaining pool coverage;
(C) Minimum residency requirements;
(D) Citizenship requirements; or
(E) Any other eligibility criteria that the board deems appropriate that are not in conflict with this part.
(d) To the extent allowed under federal law, the board may establish limits on the number of individuals covered by the pool or the duration of pool coverage, based on available funding. In determining whether to adopt limits, the board shall consider the amount of assessments required pursuant to § 56-7-2911(a)(2), and shall attempt to keep the assessments at a reasonable level through the adoption of limits, if necessary.
(e) (1) A person shall not be eligible for coverage through the pool, if:
(A) The person has or obtains health insurance coverage substantially similar to or more comprehensive than a pool policy, or would be eligible to have coverage, if the person elected to obtain it, except that:
(i) A person may maintain other coverage, including COBRA continuation coverage, for the period of time the person is satisfying any preexisting coverage waiting period under a pool policy; and
(ii) A person may maintain pool coverage for the period of time the person is satisfying a preexisting condition waiting period under another health insurance policy intended to replace the pool policy;
(B) The person is determined to be eligible for health benefits under medicaid;
(C) The person has previously terminated coverage in the pool within twelve (12) months of the date that application is made to the pool, except that this subdivision (e)(1)(C) shall not apply with respect to an applicant who is a federally defined eligible individual;
(D) The pool has paid out one million dollars ($1,000,000) in benefits on behalf of the person over the lifetime of the person;
(E) The person is an inmate or resident of a public institution, except that this subdivision (e)(1)(E) shall not apply with respect to an applicant who is a federally defined eligible individual;
(F) The person's premiums are paid for or reimbursed under any government sponsored program or by any government agency or health care provider, except as an otherwise qualifying full-time employee, or dependent thereof, of a government agency or health care provider; or
(G) The person has had prior coverage with the pool terminated for fraud.
(2) The board may establish additional criteria disqualifying individuals for pool coverage; provided, that the criteria do not apply to federally defined eligible individuals.
(f) Pool coverage shall cease:
(1) On the date a person is no longer a resident of Tennessee;
(2) On the date a person requests coverage to end;
(3) Upon the death of the covered person;
(4) On the date state law requires cancellation of the policy;
(5) At the option of the board, thirty (30) days after the pool makes any inquiry concerning the person's eligibility or place of residence to which the person does not reply;
(6) At the option of the board, on a specified number of days after the day on which a premium payment for pool coverage becomes due, if the payment is not made on or before that date; or
(7) On the date a person becomes eligible for coverage by another plan through the person's spouse or dependent.
(g) Except under the circumstances described in subsection (e), a person who ceases to meet the eligibility requirements of this section may be terminated at the end of the policy period for which the necessary premiums have been paid. Access Tennessee has the sole discretion to determine that a person does not meet the eligibility requirements.
(h) It shall constitute an unfair practice in the business of insurance, for the purposes of §§ 56-8-103 and 56-6-112, for an insurer, insurance producer or third party administrator to refer an individual to the pool, or arrange for an individual to apply to the pool, for the purpose of separating that individual from group health insurance coverage. A violation of § 56-8-103 under this section shall be punishable by law as a violation of § 56-8-104. The board has the authority and responsibility to adopt policies and procedures that effectively implement this subsection (h). The commissioner may impose a higher assessment pursuant to § 56-7-2911(a)(2) on any entity determined, after appropriate notice and an opportunity for a hearing, to have violated this subsection (h).
(i) Notwithstanding any other provision of this part to the contrary, during an initial two-month period to be determined by the board, the commissioner may waive any eligibility restriction set forth in statute or adopted by the board for any individual disenrolled from the TennCare standard category on or after August 1, 2005.
History: [Acts 2006, ch. 867, §§ 3, 14(a).]