reglab/statecodes huggingface dataset:
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-14 - Submission of final offers; supporting documentation

The parties shall have ten days after the selection of the arbitrator to submit in writing to the resolution organization each party's final offer and each party's argument in support of such offer. The parties' initial arguments shall be limited to written form and shall consist of no more than 20 pages per party. The parties may submit documents in support of their arguments. The arbitrator may require the parties to submit such additional written argument and documentation as the arbitrator determines necessary, but the arbitrator may require such additional filing no more than once. Such additional written argument shall be limited to no more than ten pages per party. The arbitrator may set filing times and extend such filing times as appropriate. Failure of either party to timely submit the supportive documentation described herein may result in a default against the party failing to make such timely submission.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-15 - Proposed payment amounts

Each party shall submit one proposed payment amount to the arbitrator. The arbitrator shall pick one of the two amounts submitted and shall reveal that amount in the arbitrator's final decision. The arbitrator may not modify such selected amount. In making such a decision, the arbitrator shall consider the complexity and circumstances of each case, including, but not limited to, the level of training, education, and experience of the relevant physicians or other individuals at the facility who are licensed or otherwise authorized in this state to furnish healthcare services and other factors as determined by the Commissioner through rule. The arbitrator's final decision shall be in writing and shall describe the basis for such decision, including citations to any documents relied upon. Notwithstanding Code Section
33-20E-14
, such decision shall be made within 60 days of the Commissioner's referral. Any default or final decision issued by the arbitrator shall be binding upon the parties and is not appealable through the court system.
Amended by 2023 Ga. Laws 223,§ 8, eff. 7/1/2023.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-16 - Payment of expenses and fees

The party whose final offer amount is not selected by the arbitrator shall pay the amount of the verdict, the arbitrator's expenses and fees, and any other fees assessed by the resolution organization, directly to such resolution organization. In the event of default, the defaulting party shall also pay such moneys due directly to such organization. In the event that both parties default, the parties shall each be responsible for paying such organization one-half of all moneys due. Moneys due under this Code section shall be paid in full to the resolution organization within 15 days of arbitrator's final decision. Within three days of such organization's receipt of moneys due to the party whose final offer was selected, such moneys shall be distributed to such party.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-17 - Referral of parties for violations

Following the resolution of arbitration, the Commissioner may refer the decision of the arbitrator to the appropriate state agency or the governing entity with governing authority over such provider or facility if the Commissioner concludes that a provider or facility has either displayed a pattern of acting in violation of this chapter or has failed to comply with a lawful order of the Commissioner or the arbitrator. Such referral shall include a description of such violations and the Commissioner's recommendation for enforcement action. Such state agency or governing entity shall initiate an investigation regarding such referral within 30 days of receiving such referral and shall conclude the investigation within 90 days of receiving such referral.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-18 - Limitation on litigation when arbitration sought

Once a request for arbitration has been filed with the Commissioner by a provider or facility under this chapter, neither such provider nor such facility nor the insurer in such dispute shall file a lawsuit in court regarding the same out-of-network claim.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-19 - Quarterly reporting by resolution organizations

Each resolution organization contracted with by the department shall report to the department on a quarterly basis the results of all disputes referred to such organization as follows: the number of arbitrations filed, settled, arbitrated, defaulted, or dismissed during the previous calendar year and whether the arbitrators' decisions were in favor of the insurer or the provider or facility.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-20 - Annual reporting by Commissioner

On or before July 1, 2022, and each July 1 thereafter, the Commissioner shall provide a written report to the House Committee on Insurance and the Senate Insurance and Labor Committee, or their successor committees, and shall post the report on the department's website summarizing the number of arbitrations filed, settled, arbitrated, defaulted, and dismissed during the previous calendar year; and a description of whether the arbitration decisions were in favor of the insurer or the provider or facility.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-21 - Exclusion from other statutory provisions

The arbitration conducted under this chapter shall be subject to neither Chapter 13 of Title 50, the "Georgia Administrative Procedure Act," nor Chapter 11 of Title 9, the "Georgia Civil Practice Act."
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-22 - Reporting to credit reporting agencies

No nonparticipating provider shall report to any credit reporting agency any covered person who receives a surprise bill for the receipt of healthcare services from such provider and does not pay such provider any copay, coinsurance, deductible, or other cost-sharing amount beyond what such covered person would pay if such nonparticipating provider had been a participating provider.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-23 - Financial responsibilities for ground ambulance transportation

Nothing in this chapter shall reduce a covered person's financial responsibilities with regard to ground ambulance transportation.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-25 - Monitoring of providers for accessibility; notification of noncompliance; responding to notification; requesting hearing

(a)
(1)
An insurer shall monitor on an ongoing basis the ability, clinical capacity, and legal authority of its participating providers to furnish all contracted covered benefits to all covered persons under a network plan.
(2)
Beginning January 1, 2025, and annually thereafter, in a manner and format as determined by the Commissioner, an insurer shall report to the Commissioner such quantitative data as necessary to demonstrate compliance with Code Section
33-20E-24
.
(b)
The Commissioner is authorized to conduct a data call, market conduct examination, or compliance audit to determine compliance with the provisions in Code Section
33-20E-24
, as authorized by Code Section
33-2-11
, and the insurer subject to such data call, market conduct examination, or compliance audit shall pay all the actual expenses incurred, in accord with Code Section
33-2-15
.
(c)
(1)
When the Commissioner determines noncompliance with the provisions in Code Section
33-20E-24
, the Commissioner shall notify the insurer of the determination and shall set forth the reasons for the determination. Prior to such determination, the Commissioner shall consider factors that might hinder an insurer's compliance, including, but not limited to, the availability of providers, the willingness of nonparticipating providers to enter into reasonable network contract agreements with an insurer, and good faith efforts by an insurer to enter into network contract agreements with such nonparticipating providers.
(2)
The Commissioner may set forth proposed remedies that will render compliance in the judgment of the Commissioner, may order that healthcare services provided by nonparticipating providers be covered at an in-network level of benefits, and may impose any administrative penalties authorized by this title.
(d)
Within 30 days of notification from the Commissioner, the insurer shall submit a response to the Commissioner that addresses all of the Commissioner's concerns.
(e)
Within 30 days of the submission of the response, the Commissioner shall determine whether such response is acceptable and shall notify the insurer of the determination and shall set forth the reasons for the determination.
(f)
If the response is deemed unacceptable to the Commissioner, the insurer shall have the right to request a hearing in accord with Code Section
33-2-17
.
Added by 2023 Ga. Laws 242,§ 2, eff. 1/1/2024, app. to all policies or contracts issued, delivered, issued for delivery, or renewed in this state on or after 1/1/2024.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-26 - Enforcement; monetary penalties

(a)
For each and every act in violation of Code Section
33-20E-24
, the Commissioner may impose a monetary penalty of up to $2,000.00, unless the insurer knew or reasonably should have known of the violation, in which case the monetary penalty imposed may be up to $5,000.00 for each and every act in violation.
(b)
The Commissioner may take any action authorized, including, but not limited to, issuing an administrative order imposing monetary penalties, imposing a compliance plan, ordering the insurer to develop a compliance plan, or ordering the insurer to reprocess claims.
Added by 2023 Ga. Laws 242,§ 2, eff. 1/1/2024, app. to all policies or contracts issued, delivered, issued for delivery, or renewed in this state on or after 1/1/2024.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20F - SELF-FUNDED HEALTHCARE PLAN OPT-IN TO THE SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20F-1 — 33-20F-5) › Section 33-20F-1 - Definitions

As used in this chapter, the term:
(1)
"ERISA" means the Employee Retirement Income Security Act of 1974,
29 U.S.C. Section 1001
, et seq.
(2)
"Insurer" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the Commissioner, that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including those of an accident and sickness insurance company, a health maintenance organization, a healthcare plan, a managed care plan, or any other entity providing a health insurance plan, a health benefit plan, or healthcare services.
(3)
"Self-funded healthcare plan" means an arrangement whereby an employer assumes the financial risk for providing healthcare benefits to its employees and such arrangement is subject to the exclusive jurisdiction of ERISA.
Added by 2021 Ga. Laws 36,§ 3, eff. 4/29/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20F - SELF-FUNDED HEALTHCARE PLAN OPT-IN TO THE SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20F-1 — 33-20F-5) › Section 33-20F-2 - Election to participate in Surprise Billing Consumer Protection Act; notices

(a)
Notwithstanding any provision of law in Chapter 20E of this title, the "Surprise Billing Consumer Protection Act," a self-funded healthcare plan may elect on an annual basis to participate in and be bound by such Act.
(b)
A self-funded healthcare plan that elects to participate in the Surprise Billing Consumer Protection Act shall provide notice to the Commissioner of its election decision on a form prescribed by the Commissioner. The completed form shall include an attestation that the self-funded healthcare plan has elected to participate in and be bound by the Surprise Billing Consumer Protection Act to the extent that insurers are similarly bound. Such form shall be posted on the Commissioner's website for use by self-funded healthcare plans choosing to opt in.
(c)
A self-funded healthcare plan may elect to initiate its participation on either January 1 of any year or on the first day of the self-funded healthcare plan's plan year of any year.
(d)
On its election form, the plan must indicate whether it chooses to affirmatively renew its election on an annual basis or whether it should be presumed to have renewed on an annual basis until the Commissioner receives advance notice from the plan that it is terminating its election as of either December 31 of a calendar year or the last day of its plan year. Notices under this subsection shall be submitted to the Commissioner at least 30 days in advance of the effective date of the election to initiate participation and 30 days in advance of the effective date of the termination of participation.
(e)
Self-funded healthcare plans opting in shall develop processes to address employee notifications or other responsibilities under ERISA that may arise from electing to participate in the Surprise Billing Consumer Protection Act.
Added by 2021 Ga. Laws 36,§ 3, eff. 4/29/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20F - SELF-FUNDED HEALTHCARE PLAN OPT-IN TO THE SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20F-1 — 33-20F-5) › Section 33-20F-3 - Website listing of participants

The department shall maintain on its website a list of all self-funded healthcare plans that have chosen to participate in and comply with the Surprise Billing Consumer Protection Act.
Added by 2021 Ga. Laws 36,§ 3, eff. 4/29/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20F - SELF-FUNDED HEALTHCARE PLAN OPT-IN TO THE SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20F-1 — 33-20F-5) › Section 33-20F-4 - Applicability

Nothing in this chapter shall be applicable to healthcare plans which are subject to the exclusive jurisdiction of ERISA, unless such plan elects to participate in and agrees to comply with the Surprise Billing Consumer Protection Act.
Added by 2021 Ga. Laws 36,§ 3, eff. 4/29/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20F - SELF-FUNDED HEALTHCARE PLAN OPT-IN TO THE SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20F-1 — 33-20F-5) › Section 33-20F-5 - Removal from participation by Commissioner; hearing

Notwithstanding any provision of law in the Surprise Billing Consumer Protection Act, in the event that a self-funded healthcare plan has chosen to participate in and comply with such Act, the Commissioner shall allow such participation. The Commissioner shall retain the authority, however, to remove or refuse to readmit such participant if the Commissioner determines that the self-funded healthcare plan is failing or previously failed to comply with the Surprise Billing Consumer Protection Act. Any self-funded healthcare plan shall have the opportunity to request a hearing pursuant to Code Section
33-2-17
prior to the effective date of such removal or denial.
Added by 2021 Ga. Laws 36,§ 3, eff. 4/29/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-1 - Definitions

As used in this chapter, the term:
(1)
"Basic health care services" means health care services which an enrolled population might reasonably require in order to be maintained in good health, including as a minimum but not restricted to preventive care, emergency care, inpatient hospital and physician care, and outpatient medical services.
(2)
"Enrollee" means an individual who has elected to contract for or participate in a health benefits plan for that individual or for that individual and that individual's eligible dependents.
(3)
"Evidence of coverage" means any certificate, agreement, or contract issued to an enrollee setting out the coverage to which he is entitled.
(4)
"Health benefits plan" means any arrangement whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services, at least part of which consists of arranging for or the provision of health care services, as distinguished from an arrangement which provides only for indemnification against the cost of such services on a prepaid basis through insurance or otherwise.
(5)
"Health care services" means any services included in the furnishing to any individual of medical or dental care or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness or injury.
(6)
"Health maintenance organization" means any person who undertakes to provide or arrange for one or more health benefits plans.
(7)
"Insurer" means every insurer authorized under this title to issue contracts of accident and sickness insurance. Health care corporations and health maintenance organizations are included within such term.
(7.1)
"Patient" means a person who seeks or receives health care services fron a health maintenance organization.
(8)
"Person" means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts, or corporations.
(9)
"Provider" means any physician, hospital, or other person who is licensed or otherwise authorized in this state to furnish health care services.
Amended by 2017 Ga. Laws 52,§ 12, eff. 7/1/2017.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-4 - Annual license fee

Every health maintenance organization subject to this chapter shall pay to the Commissioner of Insurance the annual license fee provided in Code Section
33-8-3
.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-6 - Composition of governing body; duty to establish mechanism for participation by enrollees in matters of policy and operation

(a)
The governing body of any health maintenance organization shall include providers and other individuals, provided that at least one-third of the members of the governing body shall be public members.
(b)
The governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referendums on major policy decisions, or through the use of other mechanisms.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-7 - Fiduciary responsibilities of directors, officers, or partners

Any director, officer, or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of the organization shall be responsible for the funds in a fiduciary relationship to the health maintenance organization.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-8 - Powers of organizations generally; filing of notice of exercise of powers

(a)
The powers of a health maintenance organization include, but are not limited to, the following:
(1)
The purchase, lease, construction, renovation, operation, or maintenance of hospitals, medical facilities, or both, their ancillary equipment, and such property as may reasonably be required for the organization's principal office or for such other purposes as may be necessary in the transaction of the business of the organization;
(2)
The making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation or corporations under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing health care services to enrollees;
(3)
The furnishing of health care services through providers which are under contract with or employed by the organization;
(4)
The contracting with any person for the performance on its behalf of certain functions such as marketing and enrollment;
(5)
The contracting with another insurer licensed in this state for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the organization;
(6)
The offering, in addition to basic health care services, of:
(A)
Additional health care services;
(B)
Indemnity benefits covering out-of-area or emergency services; and
(C)
Indemnity benefits, in addition to those relating to out-of-area and emergency services, provided through insurers; and
(7)
The extension of malpractice insurance to a medical group with which it has a mutually exclusive contract to provide medical services to the enrollees of the health maintenance organization; provided, however, that coverage only protects against liability arising from medical care provided to enrollees of the health maintenance organization who receive medical care at a facility under contract with or owned or operated by the health maintenance organization.
(b)
(1)
A health maintenance organization shall file notice, with adequate supporting information, with the Commissioner prior to the exercise of any power granted in paragraph (1) or (2) of subsection (a) of this Code section. The Commissioner shall disapprove the exercise of power if in his opinion it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the Commissioner does not disapprove within 90 days of the filing, it shall be deemed approved.
(2)
The Commissioner may promulgate rules and regulations exempting from the filing requirement of paragraph (1) of this subsection those activities having a de minimis effect.
Amended by 2013 Ga. Laws 265,§ 2, eff. 7/1/2013.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-9 - Establishment and maintenance of complaint system; maintenance of records of complaints; summary reports; examination of system

(a)
Every health maintenance organization shall establish and maintain a complaint system which has been approved by the Commissioner of Insurance to provide reasonable procedures for the resolution of written complaints initiated by enrollees or providers concerning health care services.
(b)
The health maintenance organization shall maintain records of written complaints concerning health care services for five years from the time the complaints are filed and shall submit to the Commissioner of Insurance a summary report at such times and in such format as the Commissioner of Insurance may require.
(c)
The Commissioner of Insurance may examine the complaint system at any time.
Amended by 2004 Ga. Laws 529, § 3, eff. 5/19/2004.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-10 - Responsibility of organizations for financial risks of providing services generally; reinsurance of risks; deposit of cash or securities with Commissioner

(a)
Every health maintenance organization shall be responsible for the assumption of full financial risk of providing basic health services to its members, except that the health maintenance organization may reinsure its risks with solvent reinsurers who qualify to transact reinsurance in this state under Code Section
33-7-14
and may enter into reinsurance treaties or agreements with such reinsurers in order to obtain reinsurance for:
(1)
The cost of providing basic health services which exceeds in the aggregate $5,000.00 per member per year;
(2)
The cost of providing basic health services to members when they are outside the health maintenance organization's service area; and
(3)
Not more than 90 percent of the amount of which the health maintenance organization's costs for any fiscal year exceed 115 percent of its income for that fiscal year, provided that all reinsurance treaties and agreements entered into by health maintenance organizations shall under this Code section also be required to meet the same standards as would be required by this title for reinsurance treaties or agreements made by a property and casualty insurer as a ceding insurer.
(b)
Each health maintenance organization shall deposit with the Commissioner cash or securities acceptable to the Commissioner in the amount of $100,000.00, provided that the Commissioner shall also have the authority to require such additional amounts of deposits as he may deem necessary to protect the enrollees of the health maintenance organization. The deposits shall be administered by the Commissioner pursuant to Chapter 12 of this title. The Commissioner shall also have the authority to waive, modify, or authorize accumulation and incremental adjustments of such deposits as he deems necessary to protect the enrollees of the health maintenance organization.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-11 - Investment of funds of organizations

With the exception of investments made in accordance with paragraphs (1) and (2) of subsection (a) and subsection (b) of Code Section
33-21-8
, the investable funds of a health maintenance organization shall be invested only in securities or other investments permitted by the laws of this state for the investment of assets constituting the legal reserves of life insurance companies or such other securities or investments as the Commissioner may permit. The investments shall be subject to the same terms, conditions, and limitations which apply to life insurance companies.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-12 - Participation in organizations by members of associations

No employer, union, trade organization, or any other association shall force its members, either by payroll deduction or other means, to join a health maintenance organization.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-14 - Annual information to enrollees

Every health maintenance organization shall annually provide to its enrollees:
(1)
A description of services and information as to where and how to secure them; and
(2)
A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-15 - Filing of annual reports; contents

(a)
Every health maintenance organization shall annually, on or before March 1, file with the Commissioner of Insurance, on forms to be designated by him and certified by at least two principal officers of said health maintenance organization, an annual statement as of December 31 of the preceding year and a copy of said report shall also be delivered to the commissioner of community health.
(b)
Such report shall be on forms prescribed by the Commissioner of Insurance and shall include:
(1)
A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding year certified by an independent public accountant;
(2)
Any material changes in the information submitted pursuant to subsection (b) of Code Section
33-21-2
;
(3)
The number of persons enrolled during the year, the number of enrollees as of the end of the year, and the number of enrollments terminated during the year;
(4)
A summary of information compiled pursuant to paragraph (3) of subsection (b) of Code Section
33-21-3
in such form as required by the commissioner of community health; and
(5)
Any other information relating to the financial condition or performance of the health maintenance organization as is necessary to enable the Commissioner of Insurance and the commissioner of community health to carry out their duties under this chapter.
Amended by 2009 Ga. Laws 102,§ 1-6, eff. 7/1/2009.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-16 - Fees and taxes

The same fees and taxes provided for in Chapter 8 of this title applicable to life insurers shall apply to and shall be imposed upon each health maintenance organization provided for in this chapter; and the organizations shall also be entitled to the same tax deductions, reductions, abatements, and credits that life insurers are entitled to receive.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-18 - Adoption of rules and regulations generally

(a)
The Commissioner of Insurance shall adopt rules and regulations necessary for the implementation of this chapter with respect to all matters of organization, control of the matters relating to business, agents, examinations, and all other Code sections not exempted by this Code section.
(b)
The commissioner of community health shall adopt rules and regulations for health maintenance organizations subject to his or her jurisdiction which are not inconsistent with this chapter and which are necessary to establish and control the standards of health care which a health maintenance organization shall maintain. Health maintenance organizations meeting the requirements of subsection (b.1) of Code Section
33-21-3
shall not be subject to the jurisdiction of the commissioner of community health.
Amended by 2009 Ga. Laws 102,§ 1-6, eff. 7/1/2009.
Amended by 2004 Ga. Laws 529, § 5, eff. 5/19/2004.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-18.1 - Emergency services requirements; restrictive formulary requirements

Every health benefits plan of every health maintenance organization shall include provisions that:
(1)
In the event a patient seeks emergency services and if necessary in the opinion of the health care provider responsible for the patient's emergency care and treatment and warranted by his or her evaluation, such emergency provider may initiate necessary intervention necessary to stabilize the condition of the patient without seeking or receiving prospective authorization by the health maintenance organization or health benefits plan. If in the opinion of the emergency health care provider a patient's condition has stabilized and the emergency health care provider certifies that the patient can be transported to another facility without suffering detrimental consequences or aggravating the patient's condition, the patient may be relocated to another facility which will provide continued care and treatment as necessary; and
(2)
When a health maintenance organization uses a restrictive formulary for prescription drugs, such use shall include a written procedure whereby patients can obtain, without penalty and in a timely fashion, specific drugs and medications not included in the formulary when:
(A)
The formulary's equivalent has been ineffective in the treatment of the patient's disease or condition; or
(B)
The formulary's drug causes or is reasonably expected to cause adverse or harmful reactions in the patient.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-19 - Promulgation of rules and regulations for licensing of agents

The Commissioner of Insurance may, after notice and hearing, promulgate any reasonable rules and regulations which are necessary to provide for the licensing of agents. "Agent" means a person directly or indirectly associated with a health benefits plan who engages in solicitation or enrollment.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-20 - Conduct of hearings generally; participation in hearings by commissioner of community health; judicial review

(a)
Except as otherwise provided in this chapter, all hearings and proceedings held under this chapter shall be conducted in accordance with Chapter 2 of this title and the Commissioner of Insurance shall have all the powers granted to him in Chapter 2 of this title.
(b)
The commissioner of community health, or his or her designated representative, shall be in attendance at the hearings and shall participate in the proceedings. The recommendation and findings of the commissioner of community health with respect to matters regarding health maintenance organizations under his or her jurisdiction relating to the quality of health care services provided in connection with any decision regarding denial, suspension, or revocation of a certificate of authority shall be conclusive and binding upon the Commissioner of Insurance. Health maintenance organizations meeting the requirements of subsection (b.1) of Code Section
33-21-3
shall not be subject to the jurisdiction of the commissioner of community health. After the hearing, or upon the failure of the health maintenance organization to appear at the hearing, the Commissioner of Insurance shall take action as is deemed advisable on written findings which shall be mailed to the health maintenance organization with a copy of the findings mailed to the commissioner of community health. The action of the Commissioner of Insurance and the recommendation and findings of the commissioner of community health shall be subject to review by the superior court having jurisdiction. The court may, in disposing of the issue before it, modify, affirm, or reverse the order of the Commissioner of Insurance in whole or in part.
(c)
Chapter 13 of Title 50, the "Georgia Administrative Procedure Act," shall apply to proceedings under this Code section to the extent that they are not in conflict with subsections (a) and (b) of this Code section.
Amended by 2009 Ga. Laws 102,§ 1-6, eff. 7/1/2009.
Amended by 2004 Ga. Laws 529, § 6, eff. 5/19/2004.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-20.1 - Regulation of HMOs by commissioner of community health

All health maintenance organizations meeting the requirements of subsection (b.1) of Code Section
33-21-3
shall not be subject to regulation by the commissioner of community health. Upon the Commissioner's determination that a health maintenance organization no longer meets the requirements of subsection (b.1) of Code Section
33-21-3
, the Commissioner shall immediately notify the commissioner of community health and such health maintenance organization shall be subject to regulation by the commissioner of community health until such time as it again meets the requirements of subsection (b.1) of Code Section
33-21-3
as determined by the Commissioner.
Amended by 2019 Ga. Laws 140,§ 2, eff. 7/1/2019.
Amended by 2009 Ga. Laws 102,§ 1-40, eff. 7/1/2009.
Added by 2004 Ga. Laws 529, § 7, eff. 5/19/2004.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-21 - Authority of commissioner of community health to contract for making of recommendations required by chapter; acceptance of recommendations

The commissioner of community health, in carrying out his obligations under subsection (b) of Code Section
33-21-3
, paragraph (4) of subsection (a) of Code Section
33-21-5
, and subsection (b) of Code Section
33-21-17
, may contract with qualified persons to make recommendations concerning the determinations required to be made by him. Such recommendations may be accepted in full or in part by the commissioner of community health.
Amended by 2009 Ga. Laws 102,§ 1-6, eff. 7/1/2009.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-22 - Applications, filings, and reports to be treated as public documents

All applications, filings, and reports required under this chapter shall be treated as public documents.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-23 - Confidentiality of medical information; claim of privileges by organizations

(a)
Any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant obtained from the person or from any provider by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except:
(1)
To the extent that it may be necessary to carry out the purposes of this chapter;
(2)
Upon the express consent of the enrollee or applicant;
(3)
Pursuant to statute or court order for the production of evidence;
(4)
The discovery of evidence; or
(5)
In the event of claim or litigation between the person and the health maintenance organization wherein such data or information is pertinent.
(b)
A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the provider who furnished the information to the health maintenance organization is entitled to claim.
Amended by 2019 Ga. Laws 140,§ 3, eff. 7/1/2019.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-24 - Rehabilitation, liquidation, or conservation of organizations

Any rehabilitation, liquidation, or conservation of a health maintenance organization shall be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the Commissioner pursuant to the law governing the rehabilitation, liquidation, or conservation of insurance companies. The Commissioner may apply for an order directing him to rehabilitate, liquidate, or conserve a health maintenance organization upon any one or more grounds set forth in Chapter 37 of this title, relating to the rehabilitation, liquidation, or conservation of insurers or when in his opinion the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the people of this state.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-25 - Organization and operation of health maintenance organizations by insurers or health care corporations

Notwithstanding any other law which may be inconsistent with this Code section, an insurer or a health care corporation licensed in this state may directly or through a subsidiary or affiliate organize and operate a health maintenance organization.
Amended by 2017 Ga. Laws 52,§ 13, eff. 7/1/2017.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-26 - Untrue or misleading statements; deceptive evidence of coverage; cancellation or nonrenewal of enrollees

(a)
No health maintenance organization or representative of a health maintenance organization may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this Code section:
(1)
A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a health benefits plan;
(2)
A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a reasonable person not possessing special knowledge regarding health care coverage as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health benefits plan, if the benefit or advantage or absence of limitation, exclusion, or disadvantage does not in fact exist; and
(3)
An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person not possessing special knowledge regarding health benefits plans and evidences of coverage for the health benefits plan to expect benefits, services, charges, or other advantages which the evidence of coverage does not provide or which the health benefits plan issuing the evidence of coverage does not regularly make available for enrollees covered under evidence of coverage.
(b)
The provisions of Chapter 6 of this title applicable to insurers shall apply to health maintenance organizations in this chapter and, for the purpose of determining whether a violation of Chapter 6 of this title has occurred, an "enrollee" as defined in this chapter shall be deemed to be an insured or a policyholder as used in Chapter 6 of this title, whichever is applicable.
(c)
An enrollee may not be canceled or nonrenewed except for the failure to pay the charge for such coverage or for such other reasons as may be promulgated by the Commissioner.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21 - HEALTH MAINTENANCE ORGANIZATIONS (§§ 33-21-1 — 33-21-29) › Section 33-21-28 - Applicability of provisions of title and of other laws to health maintenance organizations and representatives

(a)
Except as otherwise provided by law, all provisions of this title which are not in conflict with this chapter shall apply to health maintenance organizations and all other persons subject to this chapter, and specifically, the requirements and restrictions of Code Sections
33-20A-6
,
33-20A-7
,
33-20A-8
, and
33-20A-9.1
shall apply to health maintenance organizations and all other persons subject to this chapter.
(b)
Solicitation of enrollees by a health maintenance organization granted a certificate of authority or its representatives shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
(c)
Any health maintenance organization authorized under this chapter shall not be deemed to be practicing medicine and shall be exempt from the provision of Chapter 34 of Title 43, relating to the practice of medicine.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21A - MEDICAID CARE MANAGEMENT ORGANIZATIONS ACT (§§ 33-21A-1 — 33-21A-14) › Section 33-21A-1 - Short title

This chapter shall be known and may be cited as the "Medicaid Care Management Organizations Act."
Added by 2008 Ga. Laws 585,§ 1, eff. 5/13/2008.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21A - MEDICAID CARE MANAGEMENT ORGANIZATIONS ACT (§§ 33-21A-1 — 33-21A-14) › Section 33-21A-3 - Certificate of authority required; setting of rates; authority of commissioners

(a)
A care management organization shall be required to obtain a certificate of authority as a health maintenance organization pursuant to Chapter 21 of this title prior to providing or arranging health care for members pursuant to a contract with the Department of Community Health. On and after the date of issuance of its certificate of authority as a health maintenance organization, a care management organization shall comply with all provisions relating to health maintenance organizations and all provisions relating to managed health care plans, with the exception of Code Section
33-20A-9.1
.
(b)
The Commissioner of Insurance shall not have the authority to approve, disapprove, or set rates paid by the Department of Community Health to a care management organization or paid by a care management organization to a health care provider.
(c)
The Commissioner of Insurance shall not have the authority to approve, disapprove, or modify any plan offered by a care management organization or any contract between a care management organization and the Department of Community Health.
(d)
Nothing in this chapter shall be interpreted as altering the authority of the commissioner of community health.
Added by 2008 Ga. Laws 585,§ 1, eff. 5/13/2008.