(b) The board, with the approval of the commissioner, shall establish:
(1) The coverage to be provided by each option;
(2) The applicable schedule of benefits; and
(3) Any exclusions to coverage and other limitations.
(c) In establishing subsection (b), the board shall take into consideration the levels of health insurance coverage provided in the state and medical economic factors as may be deemed appropriate, and shall promulgate benefit levels, deductibles, coinsurance factors, exclusions, and limitations determined to be generally reflective of and commensurate with health insurance coverage provided through a representative number of large employers in Tennessee.
(d) The coverage options offered by the pool shall not be required to provide the mandated coverage or the mandated offers of coverage required pursuant to part 23, 24, 25 or 26 of this chapter.
(e) Pool coverage may exclude charges or expenses incurred during a period of time not to exceed twelve (12) months following the effective date of coverage, as to any condition that, during a period not to exceed six (6) months immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek diagnosis, care or treatment or for which medical advice, care or treatment was recommended or received as to the condition. The preexisting condition exclusion shall be waived to the extent to which similar exclusions, if any, have been satisfied under any prior health insurance coverage that was involuntarily terminated, if the application for pool coverage is made not later than sixty-three (63) days following the involuntary termination. In that case, coverage in the pool shall be effective from the date on which the prior coverage was terminated. The exclusions may not be applied to a federally defined eligible individual.
(f) The pool shall be payer of last resort of benefits, whenever any other benefit or source of third party payment is available. Benefits otherwise payable under pool coverage shall be reduced by all amounts paid or payable through any other health insurance coverage and by all hospital and medical expense benefits paid or payable under any workers' compensation coverage, automobile medical payment or liability insurance, whether provided on the basis of fault or nonfault, and by any hospital or medical benefits paid or payable under or provided pursuant to any state or federal law or program.
(g) Health care providers providing services to pool enrollees may not charge enrollees or third parties for health care services covered by the pool in excess of the amount payable by the pool, except for any applicable co-payments, deductibles or coinsurance.
(h) Access Tennessee shall have a cause of action against an eligible person for the recovery of the amount of benefits paid that are not for covered expenses. Benefits due from the pool may be reduced or refused as a set-off against any amount recoverable under this subsection (h).
(i) Nothing in this part shall be construed to prohibit Access Tennessee from issuing additional types of health insurance policies with different types of benefits that, in the opinion of the board, may be of benefit to those individuals otherwise eligible for coverage.
History: [Acts 2006, ch. 867, §§ 3, 14(a).]