Source: http://rules.sos.ga.gov/GAC/120-2-75
Timestamp: 2019-11-15 02:33:42
Document Index: 396784459

Matched Legal Cases: ['§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33', '§ 33']

» Subject 120-2-75
Subject 120-2-75 REGULATION OF PROVIDER SPONSORED HEALTH CARE CORPORATIONS
Rule 120-2-75-.01 Authority
This Regulation Chapter is adopted and promulgated by the Commissioner of Insurance pursuant to authority set forth in O.C.G.A. §§ 33-2-9, 33-20-5 and 33-20-32.
Rule 120-2-75-.02 Intent and Purpose
The intent of this Regulation is to set forth those requirements for provider sponsored health care corporations which are established in accordance with the provisions of Chapter 20 of Title 33 of the Official Code of Georgia Annotated for the purpose of providing medical services to citizens of this State. This Regulation is intended to protect the interests of the enrolled public and to ensure the fiscal stability of such organizations.
Rule 120-2-75-.03 Definitions
Unless otherwise provided, terms referenced in this Regulation are used as defined in O.C.G.A. §§ 33-1-2 and 33-20-3. Other terms are used in accordance with the Georgia Insurance Code and the Rules and Regulations of the Office of Commissioner of Insurance.
(a) "Basic Rates" is defined as rates for various categories of individuals that are calculated by or certified by a qualified actuary using reasonable assumptions as to expected medical expenses, administrative expenses and margins for contingencies;
(b) "Commissioner" is defined as the Commissioner of Insurance;
(c) "Enrollee" is defined as an individual who has been enrolled in a health care plan;
(d) "Provider sponsored health care corporation" ("PSHCC") is defined as a corporation formed pursuant to O.C.G.A. § 33-20-5 and which provides medical services to enrollees or subscribers;
(e) "Subscriber" is defined as a person to whom a subscriber's certificate is issued by a health care corporation;
(f) "Subscriber's Certificate" is defined as the certificate issued to a subscriber which sets forth the kinds and extent of the health care services which may be all or part of the total health care services used by or provided to a subscriber for which the corporation is liable to make total or partial payment.
Rule 120-2-75-.04 Authorization for Health Care Corporations
A provider sponsored health care corporation may be established by providers for the purpose of providing health care services to enrollees or subscribers in this State under the provisions of Chapter 20 of Title 33 of the Official Code of Georgia Annotated. Such entity may be a licensed hospital, physician or other provider sponsored entity as the Commissioner may consider. Pursuant to O.C.G.A. §§ 33-1-2 and 33-20-32, provider sponsored health care corporations are insurers and are subject to all provisions of Title 33 which are not in conflict with Chapter 20 of Title 33.
Rule 120-2-75-.05 Participation in Fund
(1) Each provider sponsored health care corporation shall obtain a certificate of authority from the Commissioner prior to establishing, maintaining and operating a health care plan in this State. In addition to the documents and information set forth in O.C.G.A. § 33-20-8, each provider sponsored health care corporation must also accompany its application for a certificate of authority with the following documents and information:
(a) A copy of the applicant's Charter or Articles of Incorporation, and all amendments thereto;
(b) A copy of the Applicant's Bylaws or other similar document regulating the conduct of the internal affairs of the applicant;
(c) A list of the names, addresses, official positions and biographical information of the persons who are to be responsible for the conduct of affairs and day-to-day operations of the applicant, including all members of the Board of Directors or the governing body or committee and the principal officers of the applicant and the names and addresses of each person entitled to cast five percent (5%) or more of the votes for selection of members of applicant's governing body;
(d) A copy of any contract form made or to be made between any provider, facility, class or providers and the applicant, and a copy of any contract made or to be made between the applicant and persons listed in subparagraph (c) above;
(e) A detailed description of the type of benefits to be furnished, including information concerning division of benefits into classes or kinds and reasons for division of benefits into classes and kinds;
(f) Every contract, policy, certificate or evidence of coverage, rider, endorsement, application or outline of coverage which it intends to use prior to use;
1. Basic rates and rating methodology accompanied by an actuarial certification, including assumptions upon which proposed levels and methods of reimbursement or other considerations for the health care services are based. The Actuarial Certification should state that the consideration for services is adequate, and makes provision for expected medical expenses, administrative expenses and margins for contingencies.
(g) Financial and other statements showing the applicant's assets, liabilities, sources of financial support, and sources of ability to cause health care services to be delivered to its enrollees, subscribers and covered dependents;
(h) A statement or map reasonably describing the counties or geographic area or areas to be served; listings of the providers by category and specialty within those counties or areas and such other detail as the Commissioner may reasonably require to ensure that services are available and accessible and to ensure continuity of service;
(i) A description of the internal grievance procedures to be utilized for the investigation and resolution of complaints and grievances by enrollees or subscribers and covered dependents;
(j) A description of the proposed quality assurance program, including the formal organizational structure, methods for developing criteria, and procedures for comprehensive evaluation of the quality of care rendered to enrollees, subscribers and covered dependents;
(k) A security deposit in the amount of at least $100,000.00 as required pursuant to O.C.G.A. § 33-3-8(b)(1);
(l) Form GID-3 Appointment of Attorney for Service of Process naming a natural person who is a resident of the State of Georgia, giving business and home address;
(m) A signed agreement stating that the provider sponsored health care corporation shall distribute certain information on a periodic basis to enrollees and subscribers regarding wellness services and preventive care offered by the provider sponsored health care corporation. Such information shall be submitted to the Office of Commissioner of Insurance for approval at least ninety (90) days before it is expected to be distributed to enrollees and subscribers.
(2) Within one hundred eighty (180) days of receipt of the completed application and a fee of $600.00, the Commissioner shall issue a certificate of authority; deny said application; or provide a written description of deficiencies in the application to the applicant.
(3) Before a certificate of authority can be issued, the Commissioner must be satisfied that:
(a) The persons responsible for the conduct of the affairs of the applicant are competent and trustworthy;
(b) The provider sponsored health care corporation has medical, administrative and financial capability to effectively provide the range of health care services as proposed in its application on a prepaid basis, except for copayments and/or deductibles; and
(c) The provider sponsored health care corporation is in compliance with the applicable provisions of the Georgia Insurance Code and the Rules and Regulations of the Georgia Insurance Department.
(4) The burden of proving compliance with the requirements necessary for issuance of a certificate of authority shall be and remain on the applicant at all times.
Rule 120-2-75-.06 Protection Against Insolvency
(1) Subscriber Surplus Requirements.
(a) A provider sponsored health care corporation shall have an initial net worth of at least one million dollars ($1,000,000) and shall thereafter maintain the minimum subscriber surplus required pursuant to O.C.G.A. § 33-20-13(d).
(b) The Commissioner may require additional subscriber surplus of provider sponsored health care corporations, which in the Commissioner's opinion is warranted by the volume of business written or such other factors as the Commissioner may deem relevant.
(c) In determining subscriber surplus, debt which is fully subordinated according to the terms applicable to domestic stock and mutual insurers as stipulated by O.C.G.A. § 33-14-15 shall not be considered on the financial statements of the corporation as a legal liability. Any interest obligation relating to the repayment of any subordinated debt must be similarly subordinated.
(2) Reinsurance Requirements. In order to further protect against insolvency and protect the subscribers of provider sponsored health care corporations, each provider sponsored health care corporation shall obtain and thereafter maintain an aggregate excess reinsurance policy that is acceptable to the Commissioner. Such policy must be procured from a company licensed and authorized to transact business in this State and must have a retention amount that is commensurate with the financial strength of the provider sponsored health care corporation.
(3) Assets and Investments. In determining the financial condition of provider sponsored health care corporations, admitted assets will be limited to those assets described in O.C.G.A. § 33-10-1. Pursuant to O.C.G.A. § 33-20-22, provider sponsored health care corporations shall invest their funds in the same manner as domestic life insurers pursuant to O.C.G.A. § 33-11-1et seq.
(4) Liabilities. Every provider sponsored health care corporation shall, when determining liabilities, include an amount estimated in the aggregate to provide for any unearned premium or subscription fees and reserves for the payment of all claims for health care expenditures which have been incurred, whether reported or unreported, which are unpaid and for which the health care corporation is or may be liable, and to provide for the expense of adjustment or settlement of such claims.
(5) Hold Harmless.
(a) Every contract between a provider sponsored health care corporation and a participating provider shall be in writing and shall set forth that in the event the health care corporation fails to pay for health care service as set forth in the contract, the enrollee or subscriber shall not be liable to the provider for any sums owed by the provider sponsored health care corporation.
(b) In the event that the participating provider contract has not been reduced to writing as required by this subsection or that the contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the enrollee or subscriber sums owed by the provider sponsored health care corporation.
(6) Continuation of Benefits. Each provider sponsored health care corporation shall have a plan satisfactory to the Commissioner for handling insolvency which guarantees the continuation of benefits to enrollees or subscribers who are confined on the date of insolvency in an inpatient facility until the earlier of their discharge or expiration of benefits.
Rule 120-2-75-.07 Financial Reports
Any provider sponsored health care corporation issued a license shall file annual and quarterly financial statements using forms prescribed by the Commissioner pursuant to O.C.G.A. § 33-20-24. The annual financial report is due March 1 each year and the quarterly statements are due 45 days after the end of each calendar quarter. The Commissioner may also require additional financial reports as are required of other insurers including but not limited to an annual audit from a certified public accountant.
Rule 120-2-75-.08 Regulation of Agents
(1) An agent representing a provider sponsored health care corporation must comply with all of the requirements for a life, accident and sickness agent in O.C.G.A. § 33-23-1et seq. and have a current license and certificate of authority to represent the health care corporation.
(2) The provider sponsored health care corporation must comply with the provisions of O.C.G.A. § 33-23-26 with regard to obtaining a certificate of authority for each agent representing the provider sponsored health care corporation as required by O.C.G.A. § 33-23-26(d), filing a certified listing of agents whose certificates of authority are to be renewed along with the appropriate fees, and maintaining a list of authorized agents as required in O.C.G.A. § 33-23-26(d).
(3) All provider sponsored health care corporation agents shall act in a fiduciary capacity in regard to monies collected or held by such agent.
Rule 120-2-75-.09 Holding Company System
Any provider sponsored health care corporation which is part of an insurance company holding system must make all required filings and disclosures mandated by Chapter 13 of Title 33.
Rule 120-2-75-.10 Amendments and Continuing Filing Requirements
Any changes to the name, address, legal structure, provider contracts, rates, services area(s), enrollee contracts, composition and identity of directors and principal officers must be filed with the Commissioner at least thirty (30) days prior to the intended effective date of the change.
Rule 120-2-75-.11 Penalties
Any person failing to comply with the requirements of this Regulation Chapter shall be subject to penalties and other enforcement action as may be appropriate under the insurance laws of the State of Georgia as well as any other applicable Georgia law.
Rule 120-2-75-.12 Severability
If any provision of this Regulation Chapter or the application thereof to any person or circumstance, is held invalid by a court of competent jurisdiction, the remainder of the Regulation Chapter or the applicability of such provisions to other persons or circumstances shall not be affected.