Tenn. Code Ann. § 56-32-104. Certificate of authority; prerequisites: Health Maintenance Organization Act of 1986 – Tennessee

Status: Enacted
Year Enacted: 1986
Year Amended: 2016
File: Download

States that the insurance commissioner, in issuing a certificate of authority, shall consider In the event the HMO enters into an agreement with any physician-hospital organization, or any other provider, provider group, or provider network, for the provision of healthcare services on a prepayment basis or other risk sharingbasis, the commissioner may not disallow the agreement on the basis that it transfers risk to the physician-hospitalorganization or other provider, provider group or provider network; or transfers the risk of payment for services to the physician-hospital organization or other provider, provider group or provider network; provided, that the HMO shall:
(i) Remain contractually responsible to its enrollees;
(ii) Enter into contractual arrangements utilizing contract provisions and arrangements that ensure compliance with applicable federal law, rule, regulation or waivers, including federal requirements; and
(iii) Assure the physician-hospital organizations, providers, provider groups, or provider networks that are at substantial financial risk obtain either aggregate or per-patient stop-loss protection insurance coverage for the healthcare services included in the scope of the arrangement; or the HMO remains contractually responsible to the subcontracted providers and provides a system for reserving for its continued liability

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