Tennessee health-insurance questions blend national medical-plan design with a layer of Tennessee-specific provisions, continuation, and program rules. This guide reviews the building blocks every health agent needs—plan types and cost-sharing—then makes the Tennessee overlay the spine: the policy provisions the Tennessee Department of Commerce & Insurance enforces, group continuation, the TennCare Medicaid program, and how the ACA marketplace works in Tennessee.

The national base: types of medical plans

Most health questions begin with how a plan balances cost, choice, and network:

• Indemnity / fee-for-service — pays a share of covered charges with broad provider choice; now uncommon.
• HMO (Health Maintenance Organization) — lowest cost, network-only care through a primary care physician (PCP) gatekeeper with referrals to specialists.
• PPO (Preferred Provider Organization) — a network with lower in-network cost but out-of-network access at a higher cost share, usually without referrals.
• EPO (Exclusive Provider Organization) — network-only like an HMO but typically no PCP/referral requirement.
• POS (Point of Service) — a hybrid using a PCP gatekeeper like an HMO while allowing out-of-network care like a PPO.

Universal cost-sharing terms apply across all designs: the premium (what you pay to have coverage), the deductible (paid before the plan shares), the copay (a flat per-visit charge), coinsurance (a percentage split after the deductible), and the out-of-pocket (OOP) maximum (the annual cap after which the plan pays 100% of covered, in-network care). A Health Savings Account (HSA) must be paired with a qualified high-deductible health plan (HDHP). Coverage is also sold group (employer-sponsored, lower cost, limited individual underwriting) versus individual (bought directly, now guaranteed issue under federal law).

The ACA floor (federal minimums)

The Affordable Care Act sets a national floor every Tennessee major-medical plan must meet:

• Guaranteed issue — insurers cannot decline an applicant for health reasons.
• No health rating — premiums vary only by age, geography, tobacco use, and family size, not health status.
• Pre-existing conditions covered — no exclusions or waiting periods for prior conditions.
• Essential health benefits — ten required categories (e.g., hospitalization, maternity, prescriptions, mental health, preventive care).
• Dependents to age 26 — adult children may stay on a parent's plan.

Tennessee builds on top of this floor; it does not subtract from it.

Required policy provisions and timelines

The Tennessee Department of Commerce & Insurance enforces the Uniform Individual Accident and Sickness Policy Provisions—the standard health-policy clauses tested heavily on the state portion:

• Entire contract — the policy plus the attached application make up the whole agreement.
• Grace period — extra time to pay a late premium before the policy lapses (length varies by payment mode).
• Free look — a window (commonly about 10 days for individual health policies) to return the policy for a full refund; verify the exact figure.
• Reinstatement — after a lapsed policy is reinstated, sickness is typically covered after about a 10-day wait while accidents are covered immediately.
• Time limit on certain defenses (incontestability) — after the policy has been in force a stated period (commonly 2–3 years), the insurer generally cannot contest it for application misstatements (except fraud, per policy terms).
• Notice of claim, proof of loss, and time of payment of claims — set deadlines for the insured to report and document a claim and for the insurer to pay promptly after acceptable proof.
• Misstatement of age / change of occupation — benefits may be adjusted to what the premium would have purchased at the correct age or risk class.

Unreasonably delaying or failing to pay a clearly covered claim can be an unfair claims settlement practice.

Group health and continuation

Group health is issued under a master contract to the employer with certificates to members, and often uses an actively-at-work eligibility rule and coordination of benefits when a person has two plans:

• Federal COBRA applies to employers with 20 or more employees and allows continuation generally up to 18 months (or 36 months for certain events such as divorce, death, or a dependent aging out). The participant pays the full premium.
• Tennessee has its own group continuation ("mini-COBRA") rules reaching some smaller employers below the federal threshold—verify the current size threshold and duration.
• A conversion privilege generally lets a terminating member move to an individual policy without proving insurability if exercised within the allowed time.

On the exam, distinguish continuation (keeping the same group plan temporarily) from conversion (moving to an individual policy with no new evidence of insurability).

Replacement and mandated benefits

• Replacement of an individual accident-and-health policy requires proper disclosure so the consumer can compare coverage before dropping existing insurance.
• Like every state, Tennessee requires insured (non-self-funded) plans to include certain state-mandated benefits. Treat these by category rather than memorizing dollar caps, which change. Self-funded ERISA plans are generally exempt from state mandates—a common exam distinction.

TennCare (Medicaid) and the ACA marketplace

• Medicaid in Tennessee is the TennCare program—the income- and need-based public program (distinct from Medicare). It is administered by the Division of TennCare, not by the Department of Insurance. Note that TennCare has historically operated largely through managed care organizations.
• The ACA marketplace in Tennessee operates through the federal platform, HealthCare.gov (Tennessee uses the federally facilitated exchange rather than a state-based one)—verify the current operational status.

Key Tennessee numbers to memorize

Common exam traps

• Confusing COBRA and Tennessee mini-COBRA. Federal COBRA = 20+ employees; Tennessee continuation reaches some smaller employers—verify the threshold.
• Mixing up continuation and conversion. Continuation keeps the group plan temporarily; conversion moves to an individual policy with no new evidence of insurability.
• Sending TennCare questions to the Department of Insurance. Tennessee Medicaid is TennCare, run by the Division of TennCare.
• Assuming a state-run ACA exchange. Tennessee uses the federal HealthCare.gov platform (verify).
• Assuming the ACA floor can be undercut. Guaranteed issue, no health rating, and pre-existing coverage are federal minimums Tennessee cannot reduce.
• Forgetting self-funded ERISA plans are usually exempt from state mandates.
• Asserting exact mandate caps or durations. Treat figures as statutory and subject to change—hedge.

Quick recap

Tennessee medical-plan questions start with national design—HMO, PPO, EPO, POS, and indemnity—and the universal cost-sharing terms (premium, deductible, copay, coinsurance, OOP max, plus HSA + HDHP), then the ACA floor: guaranteed issue, no health rating, pre-existing coverage, essential health benefits, and dependents to age 26. The Tennessee overlay is the spine: the uniform policy provisions the TDCI enforces (entire contract, grace period, ~10-day free look, reinstatement, incontestability, prompt-pay), group continuation/conversion rights, TennCare Medicaid, and the federal HealthCare.gov marketplace. Distinguish continuation from conversion, route Medicaid to TennCare, and verify any specific number, and the Tennessee health section becomes manageable.