Offering of Coverage Options — Exclusion of Charges and Expenses — Availability of Third Party Payment — Recovery of Ineligible Benefits Paid. [Effective Until June 30, 2025. See the Compiler's notes.]
Offering of Coverage Options — Exclusion of Charges and Expenses — Availability of Third Party Payment — Recovery of Ineligible Benefits Paid. [Effective Until June 30, 2025. See the Compiler's notes.]
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The program shall offer at least one (1) form of coverage to each eligible person. Coverage may be modeled after one (1) of the healthcare options offered to state employees pursuant to § 8-27-201, [repealed and reenacted; See Compiler's Notes.] or may combine a health savings account with a high deductible health plan. Coverage may also be obtained through the commercial market. The board may adopt other coverage options as appropriate.
The board, with the approval of the commissioner, shall establish:
The coverage to be provided by each option;
The applicable schedule of benefits; and
Any exclusions to coverage and other limitations.
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.
The coverage options offered by the program 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.
Program 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 program coverage is made not later than sixty-three (63) days following the involuntary termination. In that case, coverage in the program 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.
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 program may be reduced or refused as a set-off against any amount recoverable under this subsection (f).
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.
Notwithstanding this part to the contrary, no person shall be eligible for coverage through the program who is not already enrolled in the program prior to April 22, 2015.