Tenn. Comp. R. & Regs. 0780-01-76-.02

Current through December 10, 2024

Section 0780-01-76-.02 - DEFINITIONS

(1) "Allowable Benefit" means a benefit to provide medical, surgical, or hospital care or benefits.

(2) "Claims Liability" means the total of all incurred claims for allowable benefits under a self-funded qualified multiple employer welfare arrangement that is not reimbursed or reimbursable by stop-loss insurance, subrogation, or other sources.

(3) "Commissioner" means the Commissioner of Commerce and Insurance.

(4) "Health Benefit Plan" or "Plan" means a policy, contract, certificate or agreement offered by a multiple employer welfare arrangement for or to reimburse any of the costs of health care services. "Health benefit plan" includes accident only, credit health, dental, vision, Medicare supplement, or long-term care coverage issued as a supplement to liability insurance; automobile medical payment insurance; short-term and catastrophic health insurance policies; and a policy that pays on a cost-incurred basis. "Health benefit plan" does not include worker's compensation or similar insurance.

(5) "Multiple Employer Welfare Arrangement" has the meaning given in 29 U.S.C. 1002(40)(a).

(6) "Person" means any natural or artificial person including, but not limited to, an individual, partnership, association, trust, or corporation.

(7) "Qualified Actuary" means an individual who;

(a) Is a member in good standing of the American Academy of Actuaries;

(b) Is qualified to sign statements of actuarial opinion for life and health insurance company annual statements in accordance with the American Academy of Actuaries qualification standards for actuaries signing such statements;

(c) Is familiar with the valuation requirements applicable to life and health insurance companies; and

(d) Has not been found by the Commissioner (or if so found has subsequently been reinstated as a qualified actuary), following appropriate notice and hearing to have:

1. Violated any provision of, or any obligation imposed by, the Insurance Law or other law in the course of his or her dealings as a qualified actuary; or

2. Been found guilty of fraudulent or dishonest practices; or

3. Demonstrated his or her incompetence, lack of cooperation, or untrustworthiness to act as a qualified actuary; or

4. Submitted to the Commissioner during the past five (5) years an actuarial opinion or memorandum that the Commissioner rejected because it did not meet the provision of this chapter including standards set by the Actuarial Standards Board; or

5. Resigned or been removed as an actuary within the past five (5) years as a result of failure to adhere to generally acceptable actuarial standards; and

(8) "Qualified Multiple Employer Welfare Arrangement" is a multiple employer welfare arrangement that also meets the conditions of either subparagraph (a) or (b) below:

(a) Consists of ten (10) or more employers of the same trade or professional association provided that the association:

1. Has been actively in existence for at least five (5) years;

2. Has been formed and maintained in good faith for purposes other than obtaining insurance;

3. Does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee); and

4. Does not make health insurance coverage offered through the association available other than in connection with a member of the association; or

(b) Consists of ten (10) or more employers of the same non-profit business coalition for health provided that the coalition:

1. Has been actively in existence for at least five (5) years;

2. Has been formed and maintained in good faith for purposes other than obtaining insurance;

3. Does not condition membership in the coalition on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee); and

4. Does not make health insurance coverage offered through the coalition available other than in connection with a member of the coalition.

(9) "Self-funded Qualified Multiple Employer Welfare Arrangement" or "Arrangement" means a qualified multiple employer welfare arrangement that does not provide for payment of benefits solely through a policy of insurance issued by one or more authorized insurance companies.

(10) "Surplus" means the excess of assets of a self-funded qualified multiple employer welfare arrangement minus the liabilities of the arrangement.

(11) "Tennessee Insurance Law" means Tenn. Code Ann. §§56-1-101, et seq., as well as any rules promulgated thereunder.

Tenn. Comp. R. & Regs. 0780-01-76-.02

Original rule filed April 14, 2004; effective June 28, 2004.

Authority: T.C.A. § 56-26-204(b).