Section 8-27-901 - DefinitionsAs used in this part:
(1) "Administrator" means: (A) An individual, either employed by, or contracted with, the sponsor or the plan to provide administrative services on behalf of the plan; or(B) An entity with whom the sponsor contracts to provide administrative services on behalf of the plan;(2) "Days" means calendar days, unless otherwise noted;(3) "Insured" means any individual, other than the primary insured, who receives benefits under the plan;(4) "Plain language" means writing designed to ensure the reader understands the meaning of the passage as quickly, easily, and completely as possible, avoiding verbose, convoluted language, and jargon;(5) "Plan" means a self-funded plan of insurance established and funded by a sponsor pursuant to this part for the purpose of providing group life, hospitalization, disability, on-the-job injury or work-related injury program, or medical insurance, where funding for the plan is primarily derived from local tax revenues, which are used to fund, in excess of fifty-one percent (51%), the total costs of the plan, and where the benefits are paid directly through the sponsor's general assets or through a trust fund established for that purpose. A "plan" includes those to which the primary insured pays to the plan a nominal fee for the primary insured and any insureds whose relationship to the primary insured allows them to receive benefits under the plan. Whether or not the plan contracts with an administrator is not a factor in determining whether the plan meets this definition;(6) "Plan document" means a document by which a plan is established and operated;(7) "Plan participant" means either a primary insured or insured;(8) "Primary insured" means the individual employed by, or contracted with, the sponsor and to whom, based on the individual's status as an employee or contractor, the plan provides benefits;(9) "Reimbursement interest" means the plan's right of recovery of benefit amounts paid by the plan on behalf of the plan participant from the participant's recovery from a third-party tortfeasor arising from the injury or illness of the plan participant caused by such tortfeasor. "Reimbursement interest" does not include pre- or post-judgment interest;(10) "Request for subrogation or reimbursement interest" or "RSRI" means a form drafted by the plan in plain language and included in the SPD that the plan participant, their attorney, or other party in interest, may use to request that the plan provides notice of its subrogation or reimbursement interest;(11) "Settlement" means an agreement reached between a plan participant and the plan, or between the plan participant and a third-party tortfeasor or the third-party insurer, or both;(12) "Sponsor" means a county, municipality, municipal corporation, or special school district in this state that establishes and funds a plan;(13) "Subrogation interest" means the right to recovery that the plan has in any litigation or settlement arising from the injury or illness of a plan participant caused by a third-party tortfeasor. "Subrogation interest" does not include pre- or post-judgment interest;(14) "Summary of material modification" or "SMM" means a summary of any material amendment to the plan adopted by the sponsor, including, but not limited to, changes in deductibles, co-pays, and eligibility requirements; covered services or benefits; formulas; methodologies; schedules; networks; prior authorization requirements; and drug tiers;(15) "Summary plan description" or "SPD" means a summary of the plan document, which may or may not be part of the plan document;(16) "Third-party administrator" or "TPA" means an organization with which the plan contracts to process claims or manage certain other aspects of the plan, including, but not limited to, customer service, plan design, benefits notification, subrogation services, general plan administration, and appeals review;(17) "Third-party for medical services" or "third party" means a person or entity that contracts with either the plan or the third-party administrator to provide payment for claims of healthcare items or services for plan participants. The term includes, but is not limited to, a health and liability insurer, an administrator of an ERISA plan, an employee welfare benefit plan, a workers' compensation plan, CHAMPUS, Medicare, and other parties that are by statute, contract, or agreement legally responsible for payment of a claim for a healthcare item or service;(18) "Third-party insurer" means an insurer that provides insurance coverage to a third-party tortfeasor, regardless of whether the coverage is personal or commercial, including, but not limited to, automobile, income replacement, premises liability, home owners, umbrella, group life, health, workers compensation, hospitalization, and disability; and(19) "Third-party tortfeasor" means an individual or entity who commits a tort against a plan participant that causes a plan participant to require medical treatment for which the plan makes payments to a provider of medical services for the benefit, or on behalf, of the plan participant.Added by 2021 Tenn. Acts, ch. 360, s 3, eff. 7/1/2021.