56-32-107 - Evidence of coverage. - Tennessee Statutes

56-32-107. Evidence of coverage.

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

     (3)  (A)  An evidence of coverage shall contain:

                (i)  No provisions or statements that are unjust, unfair, inequitable, misleading, deceptive, that encourage misrepresentation, or that are untrue, misleading or deceptive as defined in § 56-32-113(a);

                (ii)  A clear and concise statement if a contract, or a reasonably complete summary if a certificate, of:

                     (a)  The health care services and the insurance or other benefits, if any, to which the enrollee is entitled;

                     (b)  Any limitation on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible, copayment or coinsurance feature;

                     (c)  Where and in what manner information is available as to how services may be obtained; and

                     (d)  The total amount of payment for health care services and the indemnity or service benefits, if any, that the enrollee is obligated to pay with respect to individual contracts; and

                (iii)  A clear and understandable description of the HMO's method for resolving enrollee complaints.

          (B)  Any subsequent change may be evidenced in a separate document issued to the enrollee.

     (4)  A copy of the form of the evidence of coverage to be used in this state, and any amendment to the evidence of coverage, shall be subject to the filing and approval requirements of subdivision (a)(2), unless it is subject to the jurisdiction of the commissioner under the laws governing health insurance or hospital medical service corporations, in which event the filing and approval provisions of those laws shall apply. To the extent, however, that the provisions do not apply, the requirement in subsection (c) shall be applicable.

(b)  (1)  No schedule of charges for enrollee coverage for health care services, or amendment to the schedule, may be used until a copy of the schedule, or amendment to the schedule, has been filed and approved by the commissioner.

     (2)  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 unfairly discriminatory. A certification by a qualified actuary or other qualified person acceptable to the commissioner of the appropriateness of the use of the charges, based on reasonable assumptions, shall accompany the filing together with adequate supporting information.

(c)  The commissioner shall, within a reasonable period, approve any form if the requirements of subsection (a) are met. It is unlawful to issue the form or to use the schedule of charges until approved. The commissioner, if disapproving the filing, shall notify the filer. In the notice, the commissioner shall specify the reasons for disapproval. A hearing will be granted within thirty (30) days after a request in writing by the person filing. The commissioner may require the submission of whatever relevant information the commissioner deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.

[Acts 1986, ch. 713, § 7; 2001, ch. 151, § 3; T.C.A. § 56-32-207.]