Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-4 - STATE HEALTH BENEFIT PLAN › Subject 111-4-1 - STATE HEALTH BENEFIT PLAN › Rule 111-4-1-.10 - Plan Benefits

Current through Rules and Regulations filed through June 27, 2024
(1)
Creation of Benefit
				Schedule.
The Board is authorized to establish benefit schedules for
				Options to be included in a health benefit plan for eligible persons as defined
				in Georgia law. Benefit schedules shall comply with applicable state and
				federal law. Benefit schedules shall further the plan design goals set forth by
				O.C.G.A. Sections
				45-18-3;
				20-2-883;
				20-2-913: "to (1) Provide a
				reasonable relationship between the hospital, surgical and medical benefits to
				be included and the expected distribution of expenses of each such type to be
				incurred by the covered employees and dependents; and (2) Include reasonable
				controls, which may include deductible and reinsurance provisions applicable to
				some or all of the benefits, to reduce unnecessary utilization of the various
				hospital, surgical, and medical services to be provided and to provide
				reasonable assurance of stability in the future years of the plan." Benefit
				schedules for Options may include a different schedule for Medicare enrolled
				Retirees and non-Medicare enrolled Retirees. Benefit schedules of Options shall
				be considered in the calculation of Employer and Employee Contribution Rates.
				The Regular Insurance Option benefit schedules shall be established upon
				approval of the Employer and Employee Contribution Rates for such Options. The
				Medicare Advantage Option benefit schedules shall be established upon approval
				of the Employer and Employee Contribution Rates for such Options. The dates of
				approval of Employer and Employee Contribution Rates shall be recorded in
				official minutes of Board meetings. Medicare Advantage Options must be
				developed and administered in the manner approved by the Centers for Medicare
				and Medicaid Services. Accordingly, the following subsections apply only to
				Regular Insurance Options.
(a) The
				Administrator shall authorize the use of established procedures by the TPA to
				terminate benefit payments if continuation of treatment in the mode being
				billed is not medically necessary. The TPA's procedures must ensure that the
				Member shall have the right to ask for a record review by medical
				consultants.
(b) The Administrator
				shall interpret the general schedules into specific benefit language for
				inclusion in the Summary Plan Description and for use by the TPA in
				adjudicating claim payments.
(c)
				The Administrator shall incorporate specific benefit language to be used by the
				TPA for review of utilization patterns and to implement claim cost containment
				features, including but not limited to, medical review of excessive utilization
				and audits of hospital or other claims.
(d) The Administrator shall be authorized to
				require pre-authorization by the TPA of any new medical service before approval
				for benefit payment. Generally, the service will not be considered for coverage
				unless medical consultants/advisors substantiate through literature research
				that clinical trials demonstrate the medical effectiveness of the service.
				Other guidelines, such as those of the Federal Drug Administration of the
				Centers for Medicare & Medicaid Services may also be used, at the
				discretion of the Administrator, in the determination of coverage.
(e) The Administrator shall authorize the use
				of established procedures by the TPA for obtaining additional medical
				information from members and from providers of medical services and supplies,
				in order to determine the amount and appropriateness of benefit
				payments.
(f) The Administrator
				shall establish procedures for permitting the Member to appeal an adverse
				determination of eligibility for Coverage or of a benefit, service, or Claim.
				These procedures shall be outlined in the Summary Plan Description to advise
				the Member of the process to initiate an appeal. However, the Administrator has
				delegated the final authority to the TPA for approval in accordance with the
				schedule of Benefits and the interpretation thereof. The Administrator shall
				have final authority for approval of al eligibility appeals.
(g) The Administrator may contract for or
				employ professionals from any medical discipline to advise the Administrator on
				continuing medical necessity, quality of medical care, or the level of fees
				charged by the providers of medical care.
(h) The Administrator is authorized to
				develop appropriate medical policy in conformity with the schedule of benefits
				and these regulations so that new procedures will be included for coverage when
				the new procedures are adopted as accepted medical practice and that medical
				procedures which are excessively used without significantly improving the
				treatment of an illness or injury are reviewed.