Health Maintenance Organization Act of 1986

What this document is

Tenn. Code Ann. tit. 56, ch. 32 - Health Maintenance Organization Act of 1986 is a state statute published by Public.Resource.Org bulk release of the Tennessee Code Annotated, via the Internet Archive. It is one of the Tennessee documents that insurance license exam questions are written from, including tennessee life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.

Sections cited in practice questions

Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-113(c) (Prohibited practices: limits on cancellation or nonrenewal of an enrollee)

  “An HMO may not cancel or refuse to renew an enrollee, except for reasons stated in the organization's rules applicable to all enrollees, or for the failure to pay the charge for coverage, or for other reasons promulgated by the commissioner.”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-103(a) (Certificate of authority required to establish or operate an HMO)

  “Notwithstanding any law of this state to the contrary, any person may apply to the commissioner for and obtain a certificate of authority to establish and operate an HMO in compliance with this chapter. No person shall establish or operate an HMO in this state without obtaining a certificate of...”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-107(a)(2) (Evidence of coverage: form filing and approval)

  “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 the evidence of coverage, has been filed and approved by the commissioner.”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-102 (Definition of health maintenance organization)

  ““Health maintenance organization (HMO)” means any person that undertakes to provide or arrange for basic health care services to enrollees on a prepaid basis.”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-105(c) (Hold harmless clause in provider contracts)

  “All provider contracts must include a hold harmless clause that will relieve any enrollee of a licensed HMO from any liability for services rendered by the providers except for reasonable copayment and uncovered expenses.”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-109 (Notice of change in operation)

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

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-113(d) (Prohibited practices; use of the term insurer)

  “No HMO, unless licensed as an insurer, may refer to itself as an insurer or use a name deceptively similar to the name or description of any insurance or surety corporation doing business in this state.”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-114(a) (Licensing of agents; definition of agent)

  “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. “Agent” does not include a...”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-116(c) (Effect of suspension of an HMO certificate of authority)

  “When the certificate of authority of an HMO is suspended, the HMO shall not, during the period of suspension, enroll any additional enrollees, except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-128(e) (Point of service option; out of network reimbursement rate)

  “Under the option described in subsection (b), the rate of reimbursement for health providers out of the network shall be the same as the rate of reimbursement for noncapitated providers in the network; provided, that copayment, co-insurance and other cost-sharing features may be different for out of network providers.”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-107 (Evidence of coverage; schedule of charges for enrollee coverage)

  “The charges may be established in accordance with actuarial principles for various categories of enrollees; provided, that charges applicable to an enrollee shall not be individually determined based on the status of the enrollee's health. However, the charges shall not be excessive, inadequate or...”

• Tenn. Code Ann. tit. 56, ch. 32 § 56-32-130(a)(1) (Prohibited retaliatory action)

  “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: Communicated with an enrollee with respect to the enrollee's health status, health care or treatment...”

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