reglab/statecodes huggingface dataset:
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-9 - Certificate of authority issuance

(a)
The Commissioner shall be authorized to issue a certificate of authority in accordance with this chapter and other proper requirements of the Commissioner if the Commissioner is satisfied that:
(1)
All items required to be filed are in proper form and meet his approval;
(2)
The applicant is established as a bona fide health care corporation;
(3)
The services rendered by the corporation are not an unnecessary duplication of similar services in the community served and are desirable for the public necessity and convenience;
(4)
The applicant's proposed methods of solicitation of contracts and its proposed conditions or methods of operation appear to be fair and reasonable;
(5)
The method of establishing rates charged is fair, reasonable, and adequate and the benefits to be provided are fair and reasonable, provided that rates established in accordance with the applicable provisions of this chapter and Chapter 24 of this title may differ for separate services or classes or kinds of service, including service in different facilities, and between subscribers in different groups if based upon the experience of the group or locality and between subscribers in groups and individual subscribers not in groups; and
(6)
The amount provided as working capital is only provided by individuals or groups which have no financial interest in the activities of the health care corporation. Interest charged for working capital, if any, shall be reasonable, shall be subject to the general laws of this state governing permissible rates of interest, and shall be approved by the Commissioner; and payment of interest, if any, and repayment of such working capital shall be permitted only after provision has been adequately made for operating expenses, payments of benefits, and the establishment of required services.
(b)
On an application for an original certificate of authority, the Commissioner may, in his discretion, consider and rely upon recommendations of the medical societies, the hospitals, or any other persons in the areas in which the health care corporation proposes to operate.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-10 - Expiration, renewal, and amendment of certificate of authority

(a)
All certificates of authority shall expire at 12:00 Midnight on June 30 following the date of issuance or renewal. A health care corporation desiring renewal shall file on March 1 preceding expiration a copy of its annual statement as of December 31 of the preceding year in a form approved for current use by the Commissioner, provided that the Commissioner may for good cause grant an extension of time for filing such annual statement not to exceed 60 days. If the health care corporation qualifies therefor its certificate shall be renewed annually; provided, however, that any certificate of authority shall continue in full force and effect until the new certificate is issued or specifically refused.
(b)
The Commissioner may amend a certificate of authority at any time to accord with changes in the health care corporation's charter or powers.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-11 - Refusal, revocation, or suspension of certificate of authority generally

The Commissioner may refuse to issue, or after a hearing refuse to renew, or revoke or suspend a health care corporation's certificate of authority in addition to other grounds provided for in this title if the corporation:
(1)
Violates any provision of this title other than the provisions of Code Section
33-20-12
as to which refusal, suspension, or revocation is mandatory;
(2)
Knowingly fails to comply with any lawful rule, regulation, or order of the Commissioner;
(3)
Is found by the Commissioner to be in unsound condition or in such condition as to render its further transaction of business in this state hazardous to its subscribers or to the public;
(4)
As a general scheme or plot, without just cause compels claimants to accept less than the amount due them or to bring action against it to secure full payment of claims;
(5)
Refuses to be examined or to produce its accounts, records, and files for examination by the Commissioner when required or refuses to furnish such other additional information as the Commissioner may deem advisable to consider the application for renewal of the corporation's certificate of authority;
(6)
Fails to pay any final judgment rendered against it in this state within 30 days after the judgment becomes final; or
(7)
Is affiliated with and under the same general management or interlocking directorate or ownership as another insurer or person which transacts direct insurance or other business in this state without having a certificate of authority or otherwise being authorized to do so, except as permitted under Chapter 5 of this title.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-12 - Mandatory refusal, revocation, or suspension

The Commissioner shall refuse to issue or to renew or shall revoke or suspend a health care corporation's certificate of authority:
(1)
If such action is required by any provision of this title; or
(2)
If the health care corporation no longer meets the requirements for the authority originally granted on account of deficiency in assets or otherwise.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-13 - Management of corporations; general powers; requirements as to reserves, minimum subscriber's surpluses, and charges

(a)
Health care corporations shall be governed and conducted as corporations and the necessary expenses of administering the affairs of the corporations may be paid from the payments collected from subscribers.
(b)
A health care corporation may in its discretion limit the benefits that it will furnish, may divide such benefits as it elects to furnish into classes or kinds, and may furnish different benefits with different kinds or classes of contracts. A health care corporation may also select the hospitals and other participating facilities with which it shall contract and may establish its own standards for approval of such facilities or classes of facilities as it shall determine appropriate, as well as levels of payment which may differ between participating and nonparticipating facilities and different classes of facilities, provided that the contracts shall be fair and reasonable and the standards and levels of payment shall be fair and reasonable and shall not be unfairly discriminatory against any persons or facilities or classes of persons or facilities.
(c)
A health care corporation shall establish and maintain at all times proper reserves subject to the approval of the Commissioner in accordance with such standards and requirements as the Commissioner may establish by rule or regulation after any notice and hearing required for unearned subscription fees, for unpaid claims, for unreported claims, and for other known liabilities.
(d)
A health care corporation shall at all times maintain a minimum subscriber's surplus of not less than $1 million or such higher amount as the Commissioner may require by rule or regulation after any required notice and hearing for the protection of the subscribers.
(e)
A health care corporation shall be required to charge a minimum of one-half of 1 percent of income at risk on all accounts as a contribution towards subscriber's surplus and such funds derived therefrom shall be contributed to such health care corporation's subscriber's surplus under such terms and conditions as the Commissioner may reasonably require by order or regulation after any required notice and hearing, provided that, if the Commissioner determines after notice and hearing that the level of accumulated subscriber's surplus for a health care corporation is in excess of that reasonably required for the protection of the corporation's subscribers, the Commissioner shall have the authority to suspend the operation of this subsection until such time as the corporation's accumulated subscriber's surplus has returned to a level which is adequate for the protection of policyholders but not excessive.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-14 - Acceptance of applications

When organized, health care corporations shall be authorized to accept applicants individually or in groups who may become subscribers of the corporation furnishing health care services under a contract which shall entitle each subscriber, beneficiary, and covered dependent to the health care services for such period of time as is provided in the contract.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-15 - Issuance and contents of membership certificates

(a)
Every health care corporation shall issue to its subscribers a membership certificate which shall describe the health care plan under which the subscriber is enrolled and shall specify how the holder of such contract may obtain the name or names and addresses of participating providers of health care services upon whom the subscriber shall have the right to call for health care services and the nature of such services. The description in the membership certificate shall be consistent with this chapter and the purposes thereof.
(b)
The form, size of type, general arrangement, and contents of the membership certificate shall be subject to the approval of the Commissioner and shall be filed with and approved by him in accordance with Chapter 24 of this title and such rules, regulations, and procedures as the Commissioner may from time to time prescribe.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-16 - Right to become participating physician or approved health care provider

Every doctor of medicine, every doctor of dental surgery, every podiatrist, and every health care provider within a class approved by the health care corporation who is appropriately licensed to practice and who is reputable and in good standing shall have the right to become a participating physician or approved health care provider for medical or surgical care, or both, as the case may be, under such terms or conditions as are imposed on other participating physicians or approved health care providers within such approved class under similar circumstances in accordance with this chapter.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-17 - Powers of corporations to contract for provision of health care services; receipt of payments

(a)
Any health care corporation organized or operated under this chapter and engaged in the operation of a health care plan may contract with any agency, instrumentality, or political subdivision of the United States of America or of this state for the furnishing of health care services and in aid or furtherance of said contract, may accept, receive, and administer in trust funds directly or indirectly made available by the agency, instrumentality, or political subdivision and, further, any health care corporation may subcontract with any organization which has contracted with any agency, instrumentality, or political subdivision of the United States of America or of this state for the furnishing of medical, hospital, and other health care services, by which subcontract the health care corporation undertakes to furnish the services required by the basic contract.
(b)
A health care corporation may enter into contracts with a corporation or association in this state or elsewhere so that reciprocity of benefits may be provided to subscribers; transfer of subscribers from one corporation to another may be effected to conform to the subscriber's place of residence; uniform benefits may be provided for all or for separate categories of employees and the dependents of such employees of corporations and other organizations transacting business in this state or elsewhere and a composite rate, that is, a rate representing the composite experience of the areas involved, may be charged for such employees and their dependents; or hospital or other health care services may be provided for subscribers of the corporation or other corporations or associations by means of risk sharing and other joint undertakings, including reinsurance, which the directors of the corporation may from time to time approve in accordance with the laws of this state. Group master contracts and the contracts issued to subscribers by a corporation subject to this chapter may specify the circumstances under which payments will be made and the rates of such payment to hospitals or other health care providers, wherever located, with which the corporation has no contract for hospital service or other health care service furnished the subscribers and other beneficiaries under the contract.
(c)
Each health care corporation may in its discretion receive and accept from governmental agencies payment covering all or part of the cost to provide health care services for needy or other persons. Each health care corporation may in its discretion receive and accept payments from private agencies, corporations, associations, groups of individuals, or others covering all or part of the cost of subscriptions to provide health care service for needy and other persons.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-18 - Sale of contracts providing for payment of specified charges made by participating physicians; right of subscribers to select physicians; liability of corporations for negligence of physicians

(a)
Health care corporations shall have the right to sell contracts providing for the payment of specified charges made by participating physicians furnishing medical or surgical care, or both, to the holders of such contracts, their beneficiaries, and covered dependents as provided for in this Code section.
(b)
The contracts shall not in any manner restrict the right of the holder to obtain the services of any physician nor shall such contracts attempt to control the relationship existing between any holder or beneficiary of any such contract and his physician.
(c)
The private physician-patient relationship shall be maintained, and a subscriber shall at all times have free choice of any physician or of any health care provider or facility within a class approved by the corporation in accordance with this chapter; provided, however, that nothing contained in this Code section shall be deemed to prohibit the use of either a group of participating physicians or approved health care providers and representatives of approved facilities which have been approved by the medical societies in the county or counties in which corporations operate to review charges made by physicians or other providers of health care services participating in the plan so as to ensure that the charges do not exceed the usual, customary, and reasonable charges made by other physicians or other providers of health care services for similar services and that such services are necessary and do not involve unnecessary utilization of services or facilities.
(d)
No provision of this chapter shall be construed as authorizing the corporate practice of medicine; and health care corporations shall not practice medicine. No physician rendering service or called on to render service to a member, beneficiary, or covered dependent and no other provider of health care services shall be construed to be an agent or employee of such corporation; and such corporation shall not be liable for the negligence, misfeasance, malfeasance, or nonfeasance of any provider of health care services or of any physician rendering medical or surgical services to any member, beneficiary, or covered dependent.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-19 - Regulation and supervision of corporations by Commissioner generally; payment of fees and taxes by corporations generally

Health care corporations shall be subject to regulation and supervision by the Commissioner and shall be required to pay any fees and taxes, including premium taxes, as are now or may hereafter be required of life insurers under this title in accordance with Chapters 2, 3, 8, and 12 of this title and the other applicable provisions of this title.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-20 - Submission to Commissioner of operating plan, schedule of rates, and amount of service; approval by Commissioner

Except for corporations subject to this chapter which are surviving corporations, health care corporations shall before accepting applications from subscribers in a nonprofit health care plan submit to the Commissioner a plan of operating and overhead expenses, operation cost, and salaries paid or to be paid during any current year together with a schedule of its rates to be charged and the amount of health care service contracted to be rendered, which plan, rates, and amount of service shall be first approved by the Commissioner as fair and reasonable before the corporation shall engage in business.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-21 - Approval of Commissioner of rates to be paid to providers of services

Except for corporations subject to this chapter which are surviving corporations, the Commissioner shall first approve the rates of payment to be made by health care corporations to providers of health care services on behalf of said corporation, its subscribers, beneficiaries, and covered dependents as being fair and reasonable before said corporation shall engage in business.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-22 - Investment of funds of corporations

Health care corporations shall invest in or lend their funds on security of and shall hold as invested assets only such assets as are authorized by Articles 1 and 3 of Chapter 11 of this title for the investments of assets of domestic insurance companies and such investments shall be subject to the same requirements, conditions, restrictions, and limitations as are applicable to the investments by such insurers.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-23 - Maintenance of books and records showing funds collected and disbursed; examination of books and records by Commissioner

Every health care corporation shall keep complete books and records in accordance with the requirements of the Commissioner showing all funds collected and disbursed. All books and records shall be subject to examination by the Commissioner in accordance with Chapter 2 of this title applicable to life insurers and the expenses of the examination borne by said corporation.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-24 - Filing of reports with Commissioner

Every health care corporation shall on or before March 1 in each year after it shall have commenced to do business pursuant to a certificate of authority make and file with the Commissioner a report of its affairs and operations during the year ending December 31 of the preceding year. The annual report shall be made in such form and contain such information as the Commissioner may by regulation from time to time prescribe and require in protecting the public interest and the interest of the subscribers of any health care corporation. The Commissioner may by regulation require such additional periodic reports as he may from time to time prescribe as necessary or appropriate to protect the policyholders and the public and to ensure the solvency of any health care corporation. The Commissioner may require that the reports be verified under oath by such appropriate officers or agents as he may designate by regulation and may require the reports to be published. Compliance with this Code section shall be a condition to the renewal of a certificate of authority under Code Section
33-20-10
.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-25 - Liability for expenses of Commissioner's supervisory and other activities

Any and all supervision, conservation, rehabilitation, liquidation, or examination of the affairs of any corporation by the Commissioner shall be at the expense of the corporation.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-26 - Powers of Commissioner as to protection of subscribers and public health and welfare

The Commissioner shall have the authority to take appropriate actions authorized by this title for the protection of a health care corporation's subscribers and the public health and welfare, including but not limited to those authorized in Code Section
33-2-24
, and shall have authority to institute civil actions and other appropriate proceedings authorized by and in accordance with Chapter 37 of this title to conserve the assets of, rehabilitate, or liquidate a health care corporation organized under or subject to this chapter in the same manner and under the same conditions and causes applicable to domestic life insurers under Chapter 37 of this title.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-27 - Imposition by Commissioner of administrative fine for certain acts of officers, employees, agents, or representatives of corporations

(a)
The Commissioner may after a hearing impose upon a health care corporation an administrative fine if he finds that the corporation through the acts of its officers, employees, agents, or representatives has with such frequency as to indicate its general business practice in this state:
(1)
Refused without just cause to pay proper claims arising under coverage provided by its contracts whether the claim is in favor of a subscriber or in favor of any other person entitled to the proceeds of a contract; or
(2)
Compelled without just cause subscribers, claimants, or other persons entitled to the proceeds of its contracts in this state to accept less than the amount due them or to bring action against the corporation to secure full payment or settlement of their claims.
(b)
The administrative fine imposed for violations set forth in paragraph (1) or (2) of subsection (a) of this Code section shall not exceed $1,000.00 for each act of misconduct constituting a violation; provided, however, that a fine of not more than $5,000.00 for each act of willful misconduct constituting a violation may be imposed.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-28 - Termination of organizers, agents, solicitors engaging in unfair or deceptive practices

Whenever the Commissioner finds after investigation that an organizer, agent, or solicitor of a health care corporation has unfairly or improperly solicited subscription certificates by misrepresenting the terms of the certificates or has engaged in any other unfair or deceptive practice, or for any reason is incompetent to serve as an organizer, agent, or solicitor, or that his or her services are not, in fact, needed, he or she shall order such corporation to dispense with the services and the organizer, agent, or solicitor of the corporation. The corporation shall be subject to the fines, penalties, and provisions of Chapter 6 of this title and Code Section
33-2-24
that are applicable to life insurers and their agents and that are not inconsistent with this chapter.
Amended by 2019 Ga. Laws 139,§ 1-86, eff. 7/1/2019.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-29 - Unlawful actions by unauthorized persons

It shall be unlawful for any person except a health care corporation established in accordance with this chapter and operating in accordance with authority from the Commissioner to establish, maintain, or operate a health care plan or to solicit subscribers to or enter into contracts with respect to a health care plan, provided that nothing in this chapter shall be construed as preventing a person from furnishing medical services for the prevention of disease among his employees or from furnishing such medical services as are required under the workers' compensation law or other laws of this state, as preventing any duly licensed insurance company from writing medical indemnity insurance or otherwise operating in accordance with this title, as preventing any duly authorized corporation from operating in accordance with Chapter 18 or 19 of this title, or as preventing any other duly authorized person or entity from operating in accordance with any other provisions of this title.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-30 - Resolution of disputes

Any dispute arising within the purview of this chapter with reference to the regulation and supervision of any health care corporation shall within 30 days after such dispute arises be submitted by the aggrieved person to the Commissioner for his decision with reference thereto, provided nothing in this Code section shall authorize or require the Commissioner to determine the contractual rights between the parties interested in any such corporations. After proper notice and hearing, any decisions and order of the Commissioner made pursuant to this chapter shall be binding on the persons involved unless set aside on review as provided by this Code section.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-31 - Applicability and construction of chapter

Except for corporations subject to this chapter which are surviving corporations, this chapter shall not apply to nor govern any corporation which is organized for profit or which contemplates any pecuniary gain to its shareholders or members. A corporation subject to this chapter may organize subsidiary or affiliated corporations to engage in allied business ventures in accordance with Chapters 13 and 14 of this title.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-32 - Application of other provisions of Code to health care corporations

Except where the context otherwise requires, the applicable provisions of Title 14 shall govern a health care corporation. A health care corporation shall not be considered to be a corporation described in paragraph (2) of subsection (a) of Code Section
14-3-1302
. All of the provisions of this title which are not in conflict with this chapter shall be applicable to any health care corporation subject to such modifications as the Commissioner may prescribe by order, directive, interpretation, guideline, or rule or regulation after any notice and hearing as may be required by this title.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-33 - Payment of distribution of reserved funds or surplus; requirements for initial public offering; fees, taxes, and assessments; applicability of other provisions of Title 33; regulation

(a)
No reserved funds as defined in subsection (b) of this Code section or surplus of such nonprofit health care corporation as increased pursuant to the charge required in subsection (e) of Code Section
33-20-13
shall be distributed or paid to any person as a part of any plan of conversion of a nonprofit health care corporation to a for profit health care corporation.
(b)
For the purposes of this Code section, "reserved funds" means those funds as described and defined in subsection (c) of Code Section
33-20-13
and any unassigned funds.
(c)
A health care corporation which issues shares in connection with an initial public offering shall first offer such shares to its subscribers on similar terms as such shares are offered to the public consistent with applicable federal law and regulations.
(d)
No options, warrants, or fees shall be paid to any officer, director, or trustee of a nonprofit health care corporation in connection with a conversion from a nonprofit to a for profit health care corporation or in regard to the initial public offering of a health care corporation.
(e)
A health care corporation shall be required to pay any and all fees, taxes, including premium taxes, and assessments, specifically excluding assessments with respect to the Georgia Life and Health Insurance Guaranty Association, as are required of other companies which provide life and accident and sickness insurance under Georgia law.
(f)
A health care corporation, including a surviving corporation, subject to this chapter shall be subject to all the provisions of this title not otherwise provided for in this chapter which are applicable to other insurers which provide life or accident and sickness insurance.
(g)
Any distribution of surplus funds by a surviving corporation shall be subject to regulation by the Commissioner pursuant to the provisions of this title governing distributions by insurers which provide life or accident and sickness insurance and shall in no event cause the surplus funds of the surviving corporation to be less than that of the predecessor corporation as of the date of the conversion, unless the Commissioner finds that such distribution is in the public interest.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20 - HEALTH CARE PLANS (§§ 33-20-1 — 33-20-34) › Section 33-20-34 - Conversion of nonprofit health care corporation; requirements and procedures; rules and regulations

(a)
(1)
Any health care corporation which is governed generally by Chapter 3 of Title 14, the "Georgia Nonprofit Corporation Code," and authorized under this chapter may merge with, or amend its articles of incorporation to become, a corporation governed by Chapter 2 of Title 14, the "Georgia Business Corporation Code," provided a detailed, written plan is submitted to the Commissioner for such conversion, written notice of such submission is given to the Attorney General, and, after a public hearing thereon, such plan is approved by the Commissioner after being found to be in the best interest of the company, its policyholders, and the general public.
(2)
In any such public hearing, the Attorney General may appear before the Commissioner and make such presentation as he or she shall deem to be in the public's interest. The Attorney General shall provide representation to the Commissioner in any other legal action relating thereto. Nothing in this Code section shall be construed as a limitation upon the Attorney General in providing legal representation to the Commissioner during the pendency of any decision concerning conversion.
(b)
The Commissioner may promulgate rules and regulations which are necessary to implement the provisions of this Code section.
Amended by 2019 Ga. Laws 139,§ 1-87, eff. 7/1/2019.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-1 - Short title

This article shall be known and may be cited as the "Patient Protection Act of 1996."
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-2 - Legislative findings

(a)
The General Assembly finds and declares that it is a vital government concern that the citizens of the State of Georgia have access to quality health care services and that informed consumers will be better able to identify and select plans that offer quality health care services if they are provided specific information before they enroll in health care plans. As the health care market becomes increasingly dominated by health care plans that use managed care techniques that include decisions as to the appropriateness of care, the General Assembly finds and declares that it is a vital government function to protect patients from managed care practices which have the effect of denying or limiting appropriate care. The General Assembly further finds that it is the public policy of the State of Georgia that physicians and health care providers be encouraged to advocate for medically appropriate health care for their patients.
(b)
To achieve these ends, the General Assembly declares it necessary for the Commissioner of Insurance to certify qualified managed care plans to conduct business in the State of Georgia and for the Commissioner of Insurance to establish standards for such certification.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-4 - Certification requirements; review and recertification; sanctions for failure to meet requirements; alternative methods for certification

(a)
In addition to other requirements of law, prior to offering a managed care plan to any resident in Georgia, a managed care entity must first obtain a certificate from the Commissioner of Insurance indicating that such managed care plan meets the requirements of this article. The Commissioner may impose such costs, by rule or regulation, on managed care entities as deemed necessary to carry out the provisions of this article.
(b)
The Commissioner shall establish procedures for the periodic review and recertification of qualified managed care plans.
(c)
The Commissioner shall terminate the certification of a qualified managed care plan, revoke or suspend the license of a managed care entity, or in lieu thereof impose a monetary penalty in accordance with Chapter 2 of this title, if the Commissioner determines that such plan no longer meets the applicable requirements for certification or violates any provision of this article. Before effecting any such sanction, the Commissioner shall provide the plan with notice and opportunity for a hearing on the proposed sanctions. Nothing in this Code section shall be construed as precluding other remedies at law.
(d)
The Commissioner shall establish a process for certification through alternative methods providing that:
(1)
An eligible organization, as defined in Section 1876(b) of the federal Social Security Act, shall be deemed to meet the requirements of subsections (a) and (b) of this Code section for certification as a qualified managed care plan; or
(2)
If the Commissioner finds that a national accreditation body has established requirements for accreditation of a managed care entity which offers a managed care plan that are at least equivalent to the requirements established under this article and that the eligible organization and its plans comply with the requirements of such national accreditation body, then such organization and its plans shall be deemed to meet the requirements of subsections (a) and (b) of this Code section.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-6 - Financial incentive programs prohibited; capitated payment arrangement allowed

(a)
A managed care plan may not use a financial incentive or disincentive program that directly or indirectly compensates a health care provider or hospital for ordering or providing less than medically necessary and appropriate care to his or her patients or for denying, reducing, limiting, or delaying such care. Nothing in this Code section shall be deemed to prohibit a managed care entity from using a capitated payment arrangement consistent with the intent of this Code section.
(b)
A managed care plan shall make full and timely payment or reimbursement to any health care provider or hospital in the same manner and subject to the same penalties as required of insurers for group accident and sickness insurance policies under paragraph (5) of subsection (b) of Code Section
33-30-6
.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-7 - Penalizing provider for discussing necessary or appropriate care with patient prohibited; penalty for providing records and assistance prohibited; penalty for violations

(a)
No health care provider may be penalized for considering, studying, or discussing medically necessary or appropriate care with or on behalf of his or her patient.
(b)
No health care provider may be penalized by a managed care plan for providing testimony, evidence, records, or any other assistance to an enrollee who is disputing a denial, in whole or in part, of a health care treatment or service or claim therefor.
(c)
A finding of a violation of this Code section or Code Section
33-20A-6
by a managed care plan shall constitute an unfair trade practice punishable under Article 1 of Chapter 6 of this title.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-7.1 - Application; managed care plan's liability following precertification; availability of personnel for precertification procedure

(a)
(1)
The provisions of this chapter shall apply to any managed care plan offered pursuant to Article 1 of Chapter 18 of Title 45 and to any managed care plan offered by any managed care entity.
(2)
When an enrollee, provider, facility, or home health care provider calls during regular business hours to request verification of benefits from a managed care plan, the caller shall have the clear and immediate option to speak to an employee or agent of such managed care plan who shall advise the caller that:
(A)
Such verification is only a determination of whether given health care services are a covered benefit under the health benefit plan and is not a guarantee of payment for those services; and
(B)
If the health care services so verified are a covered benefit, whether precertification is required and the phone number to request precertification.
(3)
If a managed care plan provides verification of benefits after regular business hours or by electronic or recorded means, the enrollee, provider, facility, or home health care provider making the request shall be provided by either electronic or recorded means or, at the option of the insurer, by a live person the information required in subparagraphs (A) and (B) of paragraph (2) of this subsection.
(b)
When an enrollee, provider, facility, or home health care provider obtains precertification for any covered health care service, the managed care plan is liable for such precertified services at the reimbursement level provided under the health benefit plan for such services where rendered within the time limits set in the precertification unless the enrollee is no longer covered under the plan at the time the services are received by the enrollee, benefits under the contract or plan have been exhausted, or there exists substantiation of fraud by the enrollee, provider, facility, or home health care provider.
(c)
Any managed care plan which requires precertification shall have sufficient personnel available 24 hours a day, seven days a week, to provide such precertifications for all procedures, other than nonurgent procedures; to advise of acceptance or rejection of such request for precertification; and to provide reasons for any such rejection. Such acceptance or rejection of a precertification request may be provided through a recorded or computer generated communication, provided that the individual requesting precertification has the clear and immediate option to speak to an employee or representative of the managed care plan capable of providing information about the precertification request.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-8 - Confidentiality and accuracy of patient records

Each managed care plan shall establish procedures to safeguard the privacy of individually identifiable patient information and to maintain accurate and timely records for patients.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-9 - Emergency services requirements; restrictive formulary requirements

Every managed care plan shall include provisions that:
(1)
(A)
In the event that a patient seeks emergency services and if necessary in the opinion of the emergency 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 to stabilize the condition of the patient without seeking or receiving prospective authorization by the managed care entity or managed care plan. No managed care entity or private health benefit plan may subsequently deny payment for an evaluation, diagnostic testing, or treatment provided as part of such intervention for an emergency condition. For purposes of this Code section, the term "emergency health care provider" includes without limitation an emergency services provider and a licensed ambulance service providing 911 emergency medical transportation.
(B)
No managed care entity or private health benefit plan which has given prospective authorization after the stabilization of a person's condition for an evaluation, diagnostic testing, or treatment may subsequently deny payment for the provision of such evaluation, diagnostic testing, or treatment. An acknowledgment of an enrollee's eligibility for benefits by the managed care entity or private health benefit plan shall not, by itself, be construed as a prospective authorization for the purposes of this Code section.
(C)
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 managed care plan 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.
Amended by 2006 Ga. Laws 667,§ 3, eff. 7/1/2006.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 1 - PATIENT PROTECTION (§§ 33-20A-1 — 33-20A-10) › Section 33-20A-10 - Chapter inapplicable to workers' compensation provisions

Nothing in this article shall apply to Chapter 9 of Title 34, relating to workers' compensation.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-30 - Short title

This article shall be known and may be cited as the "Patient's Right to Independent Review Act."
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-32 - Right to appeal

An eligible enrollee shall be entitled to appeal to an independent review organization when:
(1)
The eligible enrollee has received notice of an adverse outcome pursuant to a grievance procedure or the managed care entity has not complied with the requirements of Code Section
33-20A-5
with regard to such procedure; or
(2)
A managed care entity determines that a proposed treatment is excluded as experimental under the managed care plan, and all of the following criteria are met:
(A)
The eligible enrollee has a terminal condition that, according to the treating physician, has a substantial probability of causing death within two years from the date of the request for independent review or the eligible enrollee's ability to regain or maintain maximum function, as determined by the treating physician, would be impaired by withholding the experimental treatment;
(B)
After exhaustion of standard treatment as provided by the evidence of coverage or a finding that such treatment would be of substantially lesser or of no benefit, the eligible enrollee's treating physician certifies that the eligible enrollee has a condition for which standard treatment would not be medically indicated for the eligible enrollee or for which there is no standard treatment available under the evidence of coverage of the eligible enrollee more beneficial than the treatment proposed;
(C)
The eligible enrollee's treating physician has recommended and certified in writing treatment which is likely to be more beneficial to the eligible enrollee than any available standard treatment;
(D)
The eligible enrollee has requested a treatment as to which the eligible enrollee's treating physician, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat the eligible enrollee's condition, has certified in writing that scientifically valid studies using accepted protocols, such as control group or double-blind testing, published in peer reviewed literature, demonstrate that the proposed treatment is likely to be more beneficial for the eligible enrollee than available standard treatment; and
(E)
A specific treatment recommended would otherwise be included within the eligible enrollee's certificate of coverage, except for the determination by the managed care entity that such treatment is experimental for a particular condition.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-33 - Minimum expense of treatment prior to review

Except where required pursuant to Code Section
51-1-49
, a proposed treatment must require the expenditure of a minimum of $500.00 to qualify for independent review.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.